We carried out a review of the data available to us about Pendene House on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Pendene House, you can give feedback on this service.
We found the following examples of good practice.
Visiting procedures were robust to reduce the risk of COVID-19. All visitors were required to show a negative COVID-19 test, their temperature was taken, and a COVID-19 screening questionnaire completed before they entered the service.
Personal protective equipment (PPE) was worn by all visitors. Visits by friends and relatives were held in a specific room that was sanitised after every use. People had also been supported to maintain contact with friends and family during the pandemic via window visits, telephone calls and face time calls.
The service was clean and hygienic and infection prevention and control, best practice guidance was maintained. This included regular cleaning of high touch areas.
Staff had received refresher training in infection prevention and control best practice guidance. Information and ongoing government guidance in the management of COVID-19 was shared with staff.
Staff participated in the testing and vaccination programme. We observed staff wearing the correct PPE throughout our inspection. Staff spoke positively about the support they had received from the manager and provider.
People had been supported to participate in the COVID-19 testing programme and vaccination programme. People's individual risks in relation to COVID-19 had been assessed. Care plans had been developed that provided staff with guidance about people's care and support needs.
People’s experience of using this service:
People felt safe living at Pendene House and felt safe with the staff team who supported them.
The registered manager and staff team understood their responsibilities for keeping people safe from abuse and avoidable harm. Training in the safeguarding of adults had been provided and the staff team knew what to do should they be worried about someone.
Risks associated with people’s care and support had been assessed and managed.
People received their medicines in a safe way and as prescribed. Staff members responsible for supporting people with their medicines, had their competency checked on a regular basis.
New members of staff were appropriately recruited and there were suitable numbers of staff available to meet people’s needs in a safe and timely way. The staff team had the knowledge they needed to enable them to meet people’s needs.
The staff team adhered to the provider’s infection control policy. People were provided with a clean and comfortable place to live and there were appropriate spaces to enable people to either spend time on their own, or with others.
The registered manager ensured lessons were learned when things went wrong and was continually improving the service.
People’s needs had been assessed and plans of care developed. The staff team knew the care and support needs of the people they were supporting.
People were supported to eat and drink well and a balanced diet was offered. Healthcare professionals were involved in people’s care when needed.
People were involved in making decisions about their care and support whenever possible and their consent was always obtained.
People were supported to have the maximum choice and control of their lives and staff supported them in the least restrictive way possible; the polices and systems in the service supported this practice.
The staff team ensured people’s privacy and dignity were maintained and they treated people with kindness and respect. People’s wishes at the end of their life were explored.
A formal complaints process was displayed explaining what people should do, should they have a concern of any kind.
Systems were in place to monitor the quality and safety of the service being provided.
People, their relatives and staff were involved in how the service was run through meetings, the use of surveys and day to day conversations with the registered manager and the staff team.
The registered manager worked in partnership with others to ensure people received safe care and support.
More information is in the full report.
Rating at last inspection: Good (report published 14 October 2016) all the key questions were rated Good except Well Led, which was rated requires improvement.
Why we inspected: This was a planned inspection based on the previous rating.
Follow up: Going forward we will continue to monitor this service and plan to inspect in line with our re-inspection schedule for those services rated Good.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Pendene provides residential care to older people including people recovering from mental health issues and some who are living with dementia. Pendene is registered to provide care for up to 17 people. At the time of our inspection there were 15 people living at the home.
A registered manager was in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
At the last inspection of the service in May 2015 we asked the provider to make improvements in the storage of and administration of people’s medicines. We received an action plan from the provider which outlined the action they were going to take. This advised us of their plan to be compliant by January 2016. At this inspection we found that improvements had been made. Medicines were ordered, administered and stored safely, and staff were trained to administer the medicines people required. Staff sought medical advice and support from health care professionals where needed.
At the last inspection we also asked the provider to take action to make improvements in staff knowledge of the pressure relieving equipment. We found staff were now aware of how the equipment was monitored and had set up a programme of regular checks to ensure it was used safely.
At the last inspection we also asked the provider to make improvements to the audits, checks and governance in the home. We received an action plan from the provider. A series of checks had been introduced that were overseen by the registered manager and then checked by the provider.
Staff told us they had access to information about people’s care and support needs and what was important to people. People felt staff were kind and caring, and their privacy was respected in the delivery of care and their choice of lifestyle. However some of entries made by staff in the daily records did not always use the correct terminology and could be improved upon.
Relatives we spoke with were complimentary about the staff and the care offered to their relatives. People were involved in the review of their care plan, and when appropriate their relatives were involved. We observed staff positively interacted with people throughout the day and through the SOFI at lunch, where people were offered choices and their decisions were respected. People’s care and support needs had been assessed and people were involved in the development of their plan of care. Staff had access to people’s care plans and received regular updates about people’s care needs. Care plans included changes to peoples care and treatment and people attended routine health checks.
People were provided with a choice of meals that met their dietary needs. The catering staff were provided with up to date information about people’s dietary needs, and sought people’s opinions to meet their individual meal choices. There were sufficient person centred activities provided on a regular basis. Staff had a good understanding of people’s care needs, and people were able to maintain contact with family and friends. Visitors were welcome without undue restrictions.
Staff were subject to a thorough recruitment procedure that ensured staff were qualified and suitable to work at the home. They received induction and on-going training for their specific job role, and were able to explain how they kept people safe from abuse. Staff were aware of whistleblowing and what external assistance there was to follow up and report suspected abuse. There were sufficient staff available to meet people’s personal care needs and we saw staff worked in a co-ordinated manner.
The provider had a clear management structure within the home, which meant that the staff were aware who to contact out of hours. The provider undertook quality monitoring in the home supported by the registered manager. The provider had developed opportunities for people to express their views about the service. These included the views and suggestions from people using the service, their relatives and health and social care professionals. We received positive feedback from the staff from the local authority with regard to the care and services offered to people. Staff were aware of the reporting procedure for faults and repairs and had access to the maintenance to manage any emergency repairs.
This inspection took place on 13 May 2015 and was unannounced.
Pendene House is a care home that provides residential care for up to 17 people. The home specialises in caring for older people including those people living with dementia. At the time of our inspection there were nine people in residence.
A registered manager was in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
People were happy and told us that they felt safe. Staff were able to explain how they kept people safe from abuse, and knew what external authorities were available to report concerns on to. Staff were knowledgeable about their responsibilities and were trained to look after people and protect them from harm and abuse.
Staff were recruited in accordance with the provider’s recruitment procedures that ensured staff were qualified and suitable to work at the home. We observed there to be sufficient staff available to meet people’s needs and worked in a co-ordinated manner.
People received their medicines when prescribed. The provider assured us that they would make the required improvements were needed to ensure medicines were stored or managed safely.
Staff received an appropriate induction and ongoing training for their job role. Staff had access to people’s care records and were knowledgeable about people’s needs that were important to them.
Staff communicated people’s dietary needs appropriately, which protected them from the risk of losing weight. People were provided with a choice of meals that met their dietary needs. The catering staff were provided with up to date information about people’s dietary needs.
People’s care and support needs had been assessed and people were involved in the development of their plan of care. People told us they were satisfied with the care provided.
People felt staff were kind and caring, and their privacy and dignity was respected in the delivery of care and their choice of lifestyle. Relatives we spoke with were also complimentary about the staff and the care offered to their relatives.
We observed staff speak to, and assist people in a kind, caring and compassionate way, and people told us that care workers were polite, respectful and protected their privacy. We saw that people’s dignity and privacy was respected which promoted their wellbeing.
Staff had a good understanding of people’s care needs, though some documents within the care plan document lacked detail and explanation. There was an absence of instruction on how staff should monitor and when necessary adjust pressure relieving equipment.
Relatives and people using the service told us that they had developed good relationships with staff.
People were involved in the review of their care plan, and when appropriate were happy for their relatives to be involved. We observed staff offered people everyday choices and respected their decisions.
People told us that they were able to pursue their hobbies and interests that was important to them. These included the opportunity to maintain contact with family and friends as visitors were welcome without undue restrictions.
Staff told us they had access to information about people’s care and support needs and what was important to people. Care staff were supported and trained to ensure their knowledge, skills and practice in the delivery of care was kept up to date. Staff knew they could make comments or raise concerns with the management team about the way the service was run.
The provider had developed opportunities for people to express their views about the service. These included the views and suggestions from people using the service, their relatives and health and social care professionals.
Staff sought appropriate medical advice and support from health care professionals. Care plans included the changes to peoples care and treatment, and people had access to regular health checks.
People were confident to raise any issues, concerns or to make complaints. People said they felt staff listened to them and responded appropriately.
People who used the service and their relatives spoke positively about the open culture and communication with the staff. We noted that the provider interacted politely with people and they responded well to him. When we spoke with the provider, it was clear he knew people and their relatives, with the depth of conversational knowledge.
The provider had a clear management structure within the home, which meant that the staff were aware who to contact out of hours. Care staff understood their roles and responsibilities and knew how to access support. Staff had access to people’s care plans and received regular updates about people’s care needs.
Staff were aware of the reporting procedure for faults and repairs and had access to external contractors for maintenance and to manage any emergency repairs.
There were systems in place for monitoring of the building and equipment which meant people lived in an environment which was regularly maintained.
The provider had quality assurance systems, which included internal audits and monitoring of person centred planning. However, those were not used consistently and any shortfalls identified were not always recorded to help the provider monitor the improvements needed.
We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.
In the morning we observed a number of people taking part in a 'sing-a-long' with staff. People were seen to be enjoying themselves with some people getting up and having a dance. In the afternoon we noted that a musical dvd was showing on the television and a number or people sang along to the songs.
We looked at records which included the care plans for three people who used the service, along with staff recruitment and training records and records detailing the maintenance of systems and equipment within the service. We found all records were up to date and accurate and were kept securely.
We spoke with people who use the service who told us they were happy with the care they received and that they found staff to be kind and helpful. One person we spoke with confirmed that the information written about them within their care plan was accurate and that it reflected the care and support they received. Staff we spoke with had a clear understanding as to the care and support people required.
We asked two people if they felt safe at the service. One person said 'oh yes, if I had any worries I'd speak with the manager.' A second person told us 'definitely, everyone is so kind and helpful.'
We looked at training and supervision records of staff and spoke with staff about their training and the support they received. Staff told us they were supervised and felt that they were felt generally supported by the provider and registered manager. They told us they had the opportunity to attend staff meetings and express their views and ideas.
The provider had developed a quality assurance system, which included the sending out of surveys to people who use the service, their relatives along with health and social care professionals. The quality assurance system also included the holding of regular resident and staff meetings, as well as auditing health and safety within the service.
People told us that there was not a menu to choose from; however in the main they were happy with the food provided. People had the opportunity to talk about the service they received however their views had not been recorded.
Visitors told us that they were happy with the care their relative received and had been involved in the development of the persons care plan.