CQC report explained · a residential care home
What the CQC found at Tendercare Home Ltd
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Risk records, medicines systems, staff training and incident reviews had improved, although social distancing was not always followed at mealtimes and one controlled drugs recording error was corrected during the visit.
- Effective?
- Good
- This question was not assessed during this focused inspection. Its previous rating was carried forward.
- Caring?
- Good
- This question was not assessed during this focused inspection. Its previous rating was carried forward.
- Responsive?
- Good
- This question was not assessed during this focused inspection. Its previous rating was carried forward.
- Well-led?
- Requires improvement
- Management and monitoring systems had improved, and the new manager was described as approachable and supportive. However, recruitment audits, care plan involvement and life history information still needed improvement, and changes needed to be sustained.
What inspectors found, October 2021
Rated Good and no longer in special measures, but inspectors said leadership still Requires Improvement and improvements must be sustained.
This was an unannounced follow-up inspection. Inspectors visited on 16 September 2021 and gave feedback on 30 September 2021. They spoke with people, relatives, staff and healthcare professionals, and checked care, medicines, recruitment and management records.
The home had improved since its previous inadequate rating. Inspectors found people were protected from abuse and avoidable harm, received medicines as prescribed, and were supported by trained staff. Infection control arrangements were mostly in place, although people did not always socially distance at mealtimes.
Management systems had improved, including audits, incident reviews and action plans. However, some recruitment records still had gaps, care records did not always show people's involvement or life histories, and improvements needed to become consistent.
The overall rating changed from Inadequate to Good. Safe was rated Good. Well-led was rated Requires Improvement. The inspection did not reassess Effective, Caring or Responsive, so those ratings carried over from the previous comprehensive inspection.
Safer care systems
Care records contained information about identified risks, and medicines records matched what had been administered. Staff had received relevant training and understood people's needs.
“Improvements had been made and peoples care records we reviewed contained sufficient information to enable staff to provide the required support to mitigate the identified risks.” from the report
Medicines management
Medicines were recorded as administered as prescribed. Controlled drugs were stored correctly and the balance was accurate, apart from one recording error that was corrected during the inspection.
“The electronic records confirmed medication had been administered as prescribed.” from the report
Improved leadership
A new manager had brought more direction to the staff team. Relatives and staff described the atmosphere and communication as better.
“Since our last inspection a new registered manager has been appointed who has provided leadership and direction to the staff team, to drive improvements in the service.” from the report
Learning from incidents
Incidents and accidents were reviewed monthly. Records showed that the home looked for patterns and recorded actions to reduce risks.
“Improvements had been made since our last inspection and the records showed incidents were analysed for patterns and trends.” from the report
Leadership systems not yet consistent
needs fixingThe home had improved its audits and oversight, but inspectors said these changes needed to be sustained and embedded. Recruitment checks still needed further attention.
“Although improvements have been made these now needed to be sustained to ensure standards of care were maintained.” from the report
Incomplete recruitment records
needs fixingTwo of the three recruitment files checked had gaps in employment history that had not been fully explored or recorded. The provider said this would be addressed.
“We found there were gaps in the employment history that had not been fully explored and recorded for two staff members.” from the report
Care plans did not show enough involvement
needs fixingThe electronic care records did not show how people had been consulted about their care plans. Some life history information was also brief.
“The care records were electronic and those reviewed did not show how people were consulted and involved in the development of their care plan.” from the report
Social distancing at mealtimes
minorInspectors saw that people did not always socially distance during meals. This was discussed with the management team.
“We observed people did not always socially distance at mealtimes.” from the report
Fire risk assessment review delayed
needs fixingThe fire risk assessment was dated March 2019. The manager said its annual review had been delayed because of COVID-19 and was due in October 2021.
“The provider told us the annual review had been delayed due to COVID-19 and the fire risk assessment was due to be reviewed in October 2021.” from the report
- 01How are residents and relatives now involved in writing and reviewing care plans?
- 02What has been done to complete and audit the missing employment history checks for staff?
- 03Has the fire risk assessment been reviewed since the inspection, and have all recommendations been completed?
- 04How do you make sure people socially distance safely during mealtimes?
- 05How will you show that the recent improvements in audits, medicines and incident monitoring are being sustained?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried over from the comprehensive inspection in March 2020. This explanation was written from the published report of 21 October 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, February 2021
Tendercare Home Ltd is rated Inadequate and placed in special measures; inspectors found unsafe care, medicines concerns, poor safeguarding and weak management.
This was an unannounced focused inspection after whistleblowing concerns about safeguarding, medicines, moving and handling, and management. Inspectors visited on 10 November 2020 and also gathered information until 24 November. They spoke with people living at the home, relatives, staff, the provider and a healthcare professional. They reviewed care records, medicine records, staff files, training records and management checks.
The home was rated Inadequate for Safe and Well-led. Inspectors found that people were not always protected from abuse or improper treatment. Moving and handling was unsafe, pressure relief was not always provided as required, medicine records did not always match stock, and some new staff had not received essential training. Staff concerns were not always acted on.
The provider took immediate action after the concerns were shared. This included disciplinary action, arranging further training, reviewing medicines and recruiting a new manager. However, the overall rating fell from Good at the previous inspection to Inadequate. The home was placed in special measures, meaning CQC will monitor it and normally re-inspect within six months.
Infection control measures
Inspectors were assured about several infection control arrangements, including the use of protective equipment, testing and hygiene.
“We were assured that the provider was using PPE effectively and safely.” from the report
Staff availability
People spoken with said there were enough staff to meet their needs, although inspectors found gaps in staff training and competency checks.
“People we spoke with told us they were supported by enough staff to meet their needs.” from the report
Safeguarding failures
seriousConcerns about verbal abuse and an inappropriate physical intervention were substantiated. Some concerns were not reported to the local authority safeguarding team promptly.
“Systems and processes were not operated effectively to prevent abuse of people living at the home.” from the report
Unsafe care and medicines
seriousMoving and handling practices were unsafe. Medicine stock records did not match what had been administered, and there were not enough records for applying skin patches safely.
“This meant we could not be assured people had received the medicines when they needed them.” from the report
Pressure relief and falls
seriousRecords showed that pressure relief was sometimes given less often than required. Falls were recorded, but the home had not analysed them to reduce future risks.
“On 63 occasions pressure relief was provided less frequently than the two hourly intervals.” from the report
Staff training and checks
seriousSome newly employed staff had not received essential training. The home could not show regular competency checks for most areas of staff practice.
“newly employed staff had not received training essential to support people safely” from the report
Weak management oversight
seriousAudits and management systems did not identify the problems found by inspectors. Staff did not always feel confident raising concerns.
“Robust audits were not in place to monitor the medicines systems in place.” from the report
- 01What evidence can you show that all staff now have up-to-date safeguarding, fire safety and moving and handling training?
- 02How are you checking staff competency in moving and handling and other safety-critical tasks?
- 03How do you now check medicine stock balances and record where transdermal patches are applied?
- 04How are falls, pressure relief and other incidents reviewed to prevent the same risks happening again?
- 05What action has been taken since the inspection to make it safe for staff to raise concerns?
This was a focused inspection of Safe and Well-led only; Effective, Caring and Responsive were not inspected and their previous ratings were used in calculating the overall rating. This explanation was written from the published report of 16 February 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 Tendercare Home Ltd
5 rated inspections over 6 years: the service has held its Good rating throughout.
- October 2021Goodcurrent ratingup from InadequateSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2021Inadequatedown from GoodSafe: InadequateWell-led: Inadequate
- March 2020Goodup from Requires improvementSafe: GoodWell-led: Good
- October 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- February 2016GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- December 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- May 2012
Registered with the Care Quality Commission on 16 May 2012.
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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
At least 100 live-in carers within about an hour of Sandwell
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 £950 to £1,190 a week. 87 can care for a couple. 9 years' experience on average.
“God doesn't make people like her anymore!”
“Knowing Mum was in Corina's care made an enormous difference to us and we knew she was in safe hands.”
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.