CQC report explained · a nursing home
What the CQC found at Pendleton Court Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, July 2021
Rated Good; inspectors found safe care and positive management, but staffing levels sometimes left vulnerable people unsupervised.
This was an unannounced focused inspection on 30 June and 1 July 2021. One inspector spoke with people living in the home, relatives, staff and other professionals. They reviewed care, medicine, recruitment, training and management records.
The home was rated Good overall. Safe and well-led were both rated Good. Inspectors found that medicines, safeguarding, risk assessments and infection control were managed appropriately. Staff were recruited safely and lessons were taken from accidents and incidents.
There were concerns about how staff were spread across different floors. Some vulnerable people were left without supervision while staff helped others. Inspectors recommended that staffing deployment should be reviewed.
This was a focused inspection because of concerns about hygiene, staffing and care. The other three areas were not inspected during this visit, so their previous ratings were used in the overall rating.
Medicines management
Medicine records were completed accurately. Staff had suitable training and regular checks of their competence.
“Staff had completed relevant training and competence checks were undertaken regularly to ensure their skills remained up to date.” from the report
Learning from incidents
The home analysed accidents, incidents and falls for patterns. It also introduced extra checks after equipment failed.
“Accidents, incidents and falls were logged and analysed for any themes or patterns to help ensure improvement to care provision.” from the report
Communication with relatives
Relatives were kept informed through calls, newsletters and emails. Inspectors also found good engagement with relatives and staff.
“Relatives were kept informed via telephone, newsletters and e mails.” from the report
Staffing across floors
seriousStaffing levels were not consistent across the home. Some vulnerable people were left unattended while staff were helping others with personal care.
“We recommend the provider reviews and addresses deployment of staff to ensure there are sufficient staff on each unit to meet people's needs effectively.” from the report
Care file records
minorInspectors found a few documentation issues in care files. The manager agreed to address them.
“There were a few issues with documentation within care files.” from the report
Complaint responses
needs fixingSome people had not been satisfied with how complaints were answered. The management team was working to make responses more timely, open and honest.
“People had not always been happy with the response to complaints, but the management team were working hard to ensure responses were timely, open and honest.” from the report
- 01How many staff are normally available on each floor, and what happens when staff are helping someone with personal care?
- 02How are call bell response times checked, and has the planned call bell audit system been introduced?
- 03What action has been taken to correct the documentation issues in care files?
- 04How are complaints now recorded and answered, and how quickly should families expect a response?
- 05Which ratings from the previous comprehensive inspection apply to effective, caring and responsive care?
This was a focused inspection of Safe and Well-led because of concerns about hygiene, staffing and care; Effective, Caring and Responsive were not inspected and their previous ratings carried over. This explanation was written from the published report of 30 July 2021 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, January 2021
Rated Good; inspectors found safe care and effective management, although a registered manager was still completing registration.
This was a focused inspection after concerns about safeguarding, staffing, cleanliness and management. The inspection looked mainly at Safe and Well-led. Inspectors visited on 9 December 2020, reviewed records and spoke with people, staff and managers.
People told inspectors they felt safe. They found that medicines, staffing, recruitment, risk management, safety checks and infection control were managed safely. The home had increased cleaning, visitor restrictions and regular testing because of COVID-19.
The home used audits, improvement plans, meetings and questionnaires to monitor quality and listen to people. Safe and Well-led were both rated Good. The other three ratings were not inspected during this visit and were carried over from the previous comprehensive inspection.
Safe medicines
Staff administering medicines had training and competency checks. Records were completed accurately and audits were used to identify and address problems.
“Medicines were managed safely. Staff who administered medicines had received training and had their competency assessed to ensure medicines were given as prescribed.” from the report
Sufficient staffing
Inspectors found enough staff were deployed to meet people's needs. People and staff agreed that staffing levels were sufficient.
“People and staff we spoke with confirmed staffing levels were sufficient.” from the report
Infection control
The home had cleaning and infection control arrangements in place, with extra measures introduced during the COVID-19 pandemic.
“The home had robust cleaning and infection control processes in place.” from the report
Quality monitoring
The provider used audits and a continuing improvement plan to identify actions and track progress.
“We found these were robust and had been used to generate actions and drive improvements.” from the report
Listening to people
The home gathered views through resident meetings and questionnaires, and used feedback to explain changes.
“The home utilised a 'you said..we did..' process for informing people and relatives of actions taken” from the report
Manager registration in progress
minorThere was no registered manager in place when inspectors visited. The previous manager had left and the replacement was still completing registration.
“At the time of inspection the home did not have a manager registered with the Care Quality Commission.” from the report
- 01Has the replacement manager now completed registration with the Care Quality Commission?
- 02How are medicines audits used to prevent missed doses or record-keeping problems?
- 03How do you decide how many staff are needed each day for the current number and needs of residents?
- 04How are residents and relatives being kept informed about changes following their feedback?
- 05What arrangements are currently in place for infection control and visiting?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried over from the previous comprehensive inspection. This explanation was written from the published report of 8 January 2021 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 Pendleton Court Care Home
6 rated inspections over 6 years: the service has improved, from Requires improvement to Good.
- July 2021Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2021Goodstayed GoodSafe: GoodWell-led: Good
- June 2019Goodstayed GoodSafe: GoodWell-led: Good
- April 2017Goodstayed GoodSafe: GoodWell-led: Good
- October 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2015Inspected but not ratedSafe: Requires improvement
- September 2014Inspected but not rated
- October 2013
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- October 2011
Registered with the Care Quality Commission on 31 October 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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At least 100 live-in carers within about an hour of Salford
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,260 a week. 90 can care for a couple. 10 years' experience on average.
“Primrose is a very kind and compassionate healthcare professional”
“She is an exemplary carer, she is knowledgable empathetic and very respectful in the home.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.