CQC report explained · a residential care home
What the CQC found at Pendlebury Court Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Risk assessments were not always updated after incidents, including a serious fall, and there were no behaviour risk assessments for three people. Medicines were prescribed correctly, but the medicines fridge temperature was outside the recommended range and no action had been taken.
- Effective?
- Requires improvement
- Staff did not have specialist training in dementia awareness or managing behaviours that may challenge. People did not always have regular access to drinks or involvement in meal planning, although health outcomes and partnership working with professionals were good.
- Caring?
- Requires improvement
- Inspectors saw staff focusing more on tasks than on people's wellbeing. People and relatives said staff were kind when they interacted with them, and privacy, dignity and independence were respected.
- Responsive?
- Requires improvement
- There were few activities and limited interaction. Care records and reviews were not always up to date, and information such as signs, calendars and menus was sometimes wrong or missing.
- Well-led?
- Requires improvement
- Management audits did not reliably identify problems with medicines, care plans, risk assessments or incidents. The provider was open to feedback, and improvements such as correcting wrong signs began after the inspection.
What inspectors found, March 2020
Pendlebury Court Care Home was rated Requires Improvement; inspectors found risks in care planning, medicines storage, staff training and management checks.
This was an unannounced inspection on 6 February 2020. Inspectors spoke with people, relatives, staff and visiting health professionals. They observed care and checked care records, medicines records, staff files and management records.
The home was not always safe, effective, caring or responsive. Risk assessments were not always updated after incidents. Some medicines were stored at the wrong fridge temperature. People did not always receive enough drinks, meal choices or meaningful activities. Staff were often focused on tasks rather than talking with people.
There were also positive findings. People generally felt safe. There were enough staff to meet needs safely, infection control was good, and staff worked well with health professionals. The home was rated Requires Improvement in all five areas. Inspectors found three legal breaches.
Enough staff
Inspectors found there were enough staff to meet people's needs safely. Recruitment checks had also been completed.
“There were enough staff to ensure that people's needs were met safely.” from the report
People felt safe
People were protected from abuse and staff followed up safeguarding concerns correctly.
“People were protected from abuse and people told us they felt safe.” from the report
Clean environment
The home was clean and hygienic. Staff used protective equipment when needed, and the kitchen had the highest food hygiene rating.
“We observed the premises to have a high standard of cleanliness and hygiene.” from the report
Good health support
Staff worked well with health and social care professionals. Inspectors found good outcomes for people's health and wellbeing.
“People received good outcomes for their health and wellbeing. Staff worked well with other health and social care professionals to achieve this.” from the report
Dignity and choice
People's privacy, dignity and independence were respected. People could make choices, including having privacy in their own rooms.
“People were supported to have independence and make choices.” from the report
Risk assessments were not reliable
seriousRisk assessments were not always reviewed after incidents. Three people who showed behaviours that may challenge did not have behaviour risk assessments.
“Risks to people's health and wellbeing were not always assessed to ensure their needs were met in a way that protected them from harm.” from the report
Staff training
seriousStaff had not received specialist training in dementia awareness or managing behaviours that may challenge. Inspectors said this affected the ability to provide safe, person-centred care.
“This meant staff were not fully equipped with the skills and knowledge to be able to deliver person-centred care to people who may experience behaviours that may challenge.” from the report
Food and drinks
needs fixingPeople were not always offered drinks during the day and were not involved in choosing meals. The drinks station did not have cups or suitable jugs.
“People were not always involved in meal planning and did not always have regular access to drinks throughout the day.” from the report
Limited activities and interaction
needs fixingThere were very few activities on the inspection day, and staff had limited interaction with people. An activity coordinator was not employed at the time.
“We saw very few activities take place on the day of inspection and there was limited interaction with people.” from the report
Weak management checks
seriousAudits did not consistently find problems in care plans, risk assessments, medicines and incident records. This was one of the three legal breaches.
“Governance systems were not always effective in identifying areas where quality and safety of care had been compromised.” from the report
- 01What has been done to make sure risk assessments are updated after falls, incidents and changes in people's behaviour?
- 02How do you check the medicines fridge temperature each day, and what action is taken when it is outside the correct range?
- 03What dementia and behaviour support training have staff completed since this inspection?
- 04How will you make sure people are offered drinks regularly and involved in meal choices?
- 05What activities are now available, and how are they matched to each person's interests and abilities?
This was an unannounced inspection covering all five CQC key questions, with the home, care provided, records, staffing and management systems examined. This explanation was written from the published report of 13 March 2020 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, June 2018
Rated Good overall, but inspectors found weaknesses in leadership, quality checks and reporting important events.
Inspectors made an unannounced visit on 18 April 2018. They spoke with people living in the home, relatives, staff and health professionals. They observed care, medicines and interactions, and checked care plans, risk assessments, staff records and management records.
The home was rated Good for being safe, effective, caring and responsive. People had personalised care plans, appropriate staffing, safe medicines arrangements and access to health professionals. Inspectors saw kind and respectful care, and people and relatives were generally positive about the service.
The home was rated Requires Improvement for being well-led. There was no registered manager, managers had changed several times, quality checks had gaps, and important events had not always been reported to the CQC. The overall Good rating means the service met the expected standard overall, but its leadership and monitoring needed improvement.
Kind and respectful care
Inspectors saw staff supporting people patiently and respectfully. People and relatives were generally positive about how staff treated them.
“People were supported with patience, consideration and kindness and their privacy and dignity was respected.” from the report
Safe medicines
Medicines were given by trained staff and stored and administered safely. Inspectors saw staff check records, explain medicines and wait patiently while people took them.
“The provider's arrangements for the safe management of medicines were effective and appropriate.” from the report
Personalised care plans
Care plans included people's preferences, histories, risks and changing needs. Inspectors found them detailed and easy for staff to follow.
“Care plans were personalised and contained appropriate risk assessments.” from the report
No registered manager
needs fixingThere was no registered manager in post. Relatives and staff said several management changes had been unsettling.
“There was no registered manager in post, although the acting manager was present on the day of the inspection.” from the report
Quality checks had gaps
needs fixingQuality monitoring systems were inconsistent. Some audits had not been completed since the previous year, so shortfalls were not always found or acted on.
“We found systems in place to formally assess, review and monitor the quality of care were inconsistent.” from the report
Important events not always reported
needs fixingThe provider did not consistently tell the CQC and other relevant agencies about significant events when required.
“The acting manager had not always notified the Care Quality Commission of any significant events at the service as they are legally required to do.” from the report
Possible missing belongings not investigated
needs fixingA survey reported that items had allegedly gone missing from a person's room. Management had not recognised this as a complaint or investigated it until inspectors raised it.
“A recent survey showed some items had allegedly gone missing from a person's room.” from the report
Dementia-friendly design
minorThe home did not always reflect the needs of people living with dementia in its signs, colour schemes and decoration. The acting manager said this would be considered.
“Dementia friendly signage and colour schemes were not evident.” from the report
- 01Is there now a registered manager, and if not, what is the plan and timescale for registration?
- 02Have quality monitoring audits been completed consistently since the inspection, including audits of care records, medicines and the environment?
- 03How are significant events now reported to the CQC and other relevant agencies?
- 04What was the outcome of the investigation into items allegedly missing from a person's room?
- 05What changes have been made to signage and colour schemes to support people living with dementia?
This was an unannounced inspection covering all five CQC questions and giving an overall rating; the previous inspection in September 2016 had rated the service Good overall with no concerns identified. This explanation was written from the published report of 12 June 2018 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Pendlebury Court Care Home
3 rated inspections over 3 years: the service has slipped, from Good to Requires improvement.
- March 2020Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- June 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 17 January 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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