CQC report explained · a residential care home
What the CQC found at Pendrea House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found enough staff, quick responses to call bells, safe recruitment, suitable risk assessments and safe medicines administration. They noted that the effects of some as-needed pain relief were not being recorded, and the manager said this would be changed.
- Effective?
- Good
- This key question was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Caring?
- Good
- This key question was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Responsive?
- Good
- This key question was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Well-led?
- Good
- Inspectors found clear leadership, regular audits, good communication and systems for gathering the views of people, relatives and staff. Staff said they were well supported.
What inspectors found, February 2023
Pendrea House was rated Good; inspectors found safe, consistent care and strong management, with one medicines recording issue.
This was a focused inspection on 28 January 2023. One inspector spoke with people living at the home, relatives, staff and a visiting healthcare professional. They also checked care plans, medicines records, staffing information and safety records.
The home was rated Good for Safe and Well-led. Inspectors found enough staff, quick responses to call bells, safe medicines administration, suitable risk assessments and effective infection control arrangements. Staff knew people well and supported their choices and independence.
There was one minor medicines shortfall. Staff did not record whether some medicines given when needed for pain had worked. The manager agreed to arrange for this to be recorded in future.
The overall rating stayed Good. The inspection did not review Effective, Caring or Responsive, so those ratings were carried forward from the previous inspection in 2017.
Enough staff
Inspectors found enough staff to meet people's needs. Call bells were answered quickly, and the staff team was stable.
“There were enough staff to support people safely and according to their needs and preferences.” from the report
Staff knew people well
Many staff had worked at the home for several years. This helped them provide consistent care based on people's needs and preferences.
“Some staff had worked at the service for several years. This meant people were supported by staff who knew them well.” from the report
Safe medicines practice
People received medicines as prescribed. Staff had training, regular competency checks and guidance on when as-needed medicines could be given.
“People received their medicines as prescribed. Care plans contained information about when and how medicines should be administered.” from the report
Good communication and leadership
Staff understood their roles and said they could approach the manager for advice. Changes in people's needs were shared with staff.
“Any changes in people's care needs was shared with staff at handovers and throughout the day.” from the report
People's views were gathered
Residents' meetings, care plan reviews and staff meetings gave people opportunities to share views and suggest changes.
“People were asked for their views at residents' meetings.” from the report
Pain relief records
minorWhen some as-needed pain medicines were given, staff did not record whether they had worked. The manager said this would be recorded in future.
“Staff did not record if the medicine had been effective.” from the report
- 01How do you now record whether as-needed pain relief has worked?
- 02How quickly are call bells usually answered, and how do you monitor this?
- 03How are changes in a resident's care needs shared with all staff?
- 04How are residents and relatives involved in care plan reviews?
- 05What were the ratings for Effective, Caring and Responsive at the previous inspection?
This was a focused inspection of Safe and Well-led only; the other ratings were carried forward from the previous inspection published on 27 September 2017. This explanation was written from the published report of 10 February 2023 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, March 2021
Inspected but not rated; inspectors found good infection control during and after a COVID-19 outbreak.
This was an announced, targeted inspection on 11 March 2021. It looked at infection prevention and control because the home had experienced a COVID-19 outbreak.
Inspectors found clean, uncluttered areas, effective cleaning, good supplies of personal protective equipment and appropriate testing. Staff had completed infection control training, and the home followed procedures for uniforms, social distancing and visitors.
The home also kept in regular contact with people and families. Staff worked with healthcare professionals, supported people to contact relatives by phone and video, and had increased staffing to provide emotional support.
The service was inspected but not rated. This means the inspection did not give a full overall rating or ratings for all five areas.
Infection control
The home increased cleaning hours, kept areas clean and uncluttered, and maintained supplies of PPE and antibacterial wipes.
“All areas of the service were clean and uncluttered.” from the report
Communication
The registered manager kept people, staff and families informed about measures during the outbreak.
“During this time the registered manager had communicated with people, staff and families regularly to ensure everyone understood the measures put in place to help keep people safe.” from the report
Testing and vaccination
The home introduced testing in line with national guidance and made arrangements for people and staff to access vaccination.
“Appropriate testing procedures had been implemented for all staff and people who used the service, following national guidance regarding the frequency and type of testing.” from the report
Healthcare support
Staff had daily contact with the GP and worked with healthcare professionals to arrange appropriate care and equipment.
“There were daily calls with the GP, where staff reported people's daily observation results and any concerns about their health.” from the report
Support during isolation
Extra staff helped provide emotional support and one-to-one activities while normal social contact was restricted.
“The increased staffing levels enabled staff to spend one-to-one time with people, to engage in activities of their choice, to help prevent the adverse effects of social isolation.” from the report
Inspectors raised no specific concerns in this report.
- 01How have the cleaning hours and infection control arrangements been maintained since this inspection?
- 02What testing and vaccination arrangements are currently in place for residents and staff?
- 03How are visitors currently managed, and what happens if there is another infection outbreak?
- 04How will you support my relative to stay in touch with family if visits are restricted?
- 05What recent inspection information covers the areas that this targeted inspection did not assess?
This was a targeted inspection of infection prevention and control only; it did not rate the other four questions or give an overall service rating. This explanation was written from the published report of 18 March 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 Pendrea House
3 rated inspections over 7 years: the service has held its Good rating throughout.
- February 2023Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2021Inspected but not ratedSafe: Inspected but not rated
- September 2017Goodstayed GoodSafe: GoodWell-led: Good
- September 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2013
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 10 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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