We carried out a review of the data available to us about Pendrea 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 Pendrea House, you can give feedback on this service.
Pendrea House is a care home that can accommodate up to 16 older people, some of whom may have a diagnosis of dementia. On the day of the inspection there were 14 people living at the service.
People’s experience of using this service and what we found
There were enough staff to support people safely. Staff were unhurried in their approach and responded to call bells quickly. Many of the staff had worked at the service for several years, they knew people well and provided consistent care which took account of people’s needs and preferences.
People received medicines safely and as prescribed. Staff administering medicines had received training which was regularly refreshed. Competency assessments were completed to ensure staff continued to follow good working practice when administering medicines.
Staff were aware if people were at risk due to their health condition. Risk assessments contained information about how to support people safely.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
The registered manager was supported by a deputy manager and team leaders. Staff told us they were well supported by the registered manager and were kept aware of any changes in people’s needs.
There were systems in place to gather stakeholder’s feedback. People were asked for their opinions on matters affecting the whole service as well as their individual care needs.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was good (published 27 September 2017).
Why we inspected
This inspection was prompted by a review of the information we held about this service. We undertook a focused inspection to review the key questions of safe and well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has remained good based on the findings of this inspection.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Pendrea House on our website at www.cqc.org.uk.
Follow up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.
We found the following examples of good practice.
There had been an outbreak of Covid-19 at the service. 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.
All areas of the service were clean and uncluttered. Effective cleaning routines had been put in place to ensure infection control risks were minimised and people were kept safe. Domestic staff hours had been increased at the start of the pandemic and further increased when the outbreak occurred. The additional cleaning hours were still being maintained and there were no immediate plans to reduce these hours. There were ample supplies of PPE and anti-bacterial wipes around the service for staff to use. There were posters to prompt and remind staff about the infection control procedures in place.
Staff had completed online infection prevention and control and Covid-19 training. Additional PPE had been provided for staff, such as visors, to use during the outbreak. The service had maintained good stocks of PPE and the registered manager worked with care and domestic staff teams to ensure infection prevention and control measures were followed.
Staff put on and took off their uniforms in a designated room, close to where they entered the building, and uniforms were laundered at the service. This helped to reduce the risk of infection because staff did not enter areas of the home, where people lived, until appropriate infection control measures were in place.
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. The registered manager said both staff and people were happy to participate in regular testing. Arrangements had been made to enable people and staff to access the vaccine.
During the outbreak the registered manager had worked closely with external healthcare professionals to enable people to have access to the appropriate health care and equipment, for example, oxygen if needed. There were daily calls with the GP, where staff reported people’s daily observation results and any concerns about their health. This meant, for people who were unwell with Covid, the right care could be provided in a timely manner.
Since the start of the pandemic additional care staff had been recruited, to cover staff absences and to increase staffing levels on an on-going basis. This had ensured they were enough staff on duty to provide emotional support for people living at the service throughout the pandemic and the outbreak. Before the pandemic external entertainers had visited the home daily and people had enjoyed these visits and the social interaction. 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.
Due to the recent outbreak the service was closed to visitors at the time of the inspection. However, staff helped people to stay in touch with family and friends through phone and video calls. The registered manager was in discussion with people and their families about resuming visiting in line with recent changes to government guidance.
The provider had reviewed the infection control policy in response to the pandemic. Specific Covid-19 policies had also been developed to provide guidance for staff about how to respond to the pandemic and the outbreak. These policies were kept under continuous review as changes to government guidance was published.
Further information is in the detailed findings below.
We carried out this inspection on 12 September 2017. At the last inspection, in August 2015, the service was rated Good. At this inspection we found the service remained Good.
People, and their relatives, told us they were happy with the care they received and believed it was a safe environment. Comments from people included, “I am happy and feel safe living here”, “It’s a wonderful place, I am very happy” and “Marvellous, couldn’t wish for anything better.”
On the day of our inspection there was a calm, relaxed and friendly atmosphere in the service. We observed that staff interacted with people in a caring and compassionate manner. People told us, staff were kind to them and respected their wishes. Comments from people and relatives included, “I like to be independent. Staff respect that and allow me to be me”, “All the staff are very good”, “Staff treat you well, very kind” and “Can’t fault them, staff are very helpful.”
There were enough suitably qualified staff on duty and additional staff were allocated if peoples’ needs increased, such as when someone was unwell. There were safe and robust recruitment processes in place to ensure only staff with the appropriate skills and knowledge were employed. Staff had received training in how to recognise and report abuse.
Staff ensured people kept in touch with family and friends. Relatives told us they were always made welcome and were able to visit at any time.
Safe arrangements were in place for the storing and administration of medicines. People were supported to take their medicines at the right time by staff who had been appropriately trained. Some people managed certain aspects of their own medicines and this had been appropriately agreed with the individual and any potential risks explained. No one at the service required their medicines to be administered covertly (disguised in food).
People had access to healthcare services such as occupational therapists, GPs, chiropodists and community nurses. Visitors told us staff always kept them informed if their relative was unwell or a doctor was called. A healthcare professional told us, “I have confidence in the service. Staff have the knowledge to recognise when to contact us for help and support.”
Care records were up to date, had been regularly reviewed, and accurately reflected people’s care and support needs. Details of how people wished to be supported were personalised to the individual and provided clear information to enable staff to provide appropriate and effective support. Any risks in relation to people’s care and support were identified and appropriately managed.
People had a choice of meals and staff were knowledgeable about people’s likes, dislikes and dietary needs. People told us they enjoyed their meals. Comments from people and their relatives included, “I enjoy the food, it is well cooked”, “Excellent choice”, “He enjoys the food, he doesn’t like pork and they make sure he has beef or chicken instead. He also has a fridge in his room” and “Always a choice of two meals and If you don’t like them you can have a jacket potato with a slice of meat.”
People were able to take part in a range of activities facilitated by staff and external entertainers. These included playing cards, board games, singing sessions, pamper sessions, exercises and craft work. One person told us, “I played cards yesterday and I have my nails done every week.”
Management and staff had a good understanding of the Mental Capacity Act 2005 (MCA). Where people did not have the capacity to make certain decisions the management and staff acted in accordance with legal requirements under the MCA. Staff applied the principles of the MCA in the way they cared for people and told us they always assumed people had mental capacity.
There was a management structure in the service which provided clear lines of responsibility and accountability. Staff had a positive attitude and the management team provided strong leadership. There was a stable staff team where many staff had worked at the service for a number of years. Staff told us they felt supported by the management commenting, “Good team work and good communication”, “Management are open to new ideas and we are included in decisions about the home” and “We are not afraid to speak up about anything.”
People and their families were given information about how to complain. People and relatives all described the management of the home as open and approachable. Relatives told us, “The home is well run, if you ask for something to be done it is always quickly actioned” and “I would not hesitate to recommend the home. They give excellent care.” There were regular ‘residents’ meetings which gave people the opportunity to be involved in the running of the service.
There were effective quality assurance systems in place to make sure that any areas for improvement were identified and addressed. The registered manager regularly worked alongside staff and this enabled them to observe staff practice and check if people were happy and safe living at Pendrea House.
The inspection was unannounced and took place on 27 August 2015. Our last inspection was on 22 July 2013 on and we found the service was meeting all the legal requirements.
Pendrea House provides care and accommodation for up to 16 people. On the day of the inspection 16 people were living in the home, one person was on respite care and another person was attending for day care support. Pendrea House provides care for people who are elderly, may suffer with mild mental health conditions, dementia and/or have restricted mobility.
The service had a manager in post, they were in the process of applying to be the registered manager. Their interview was the week following the inspection. 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.
During the inspection people and staff appeared relaxed, there was a calm and pleasant atmosphere. Comments included “It just feels so homely, staff are friendly and care” and, “The staff are so kind.” We observed and people told us they had the freedom to move around freely as they chose and enjoyed living in the home.
People spoke highly about the care and support they received, one person said, “The care here is good.” Another said, “It’s lovely here and the staff are so polite, kind and caring.” Care records were personalised and gave people control where possible. Staff responded quickly to people’s change in needs. People and their family were involved in identifying their needs and how they would like to be supported. People’s preferences were sought and respected, for example, if people liked to stay in their bedrooms or relax in one of the lounges.
People’s risks and environmental risks were managed well and monitored. People were promoted to live full and active lives and participate in the activities if they wished, many enjoyed relaxing in the beautiful gardens. Activities reflected people’s interest and pastimes they enjoyed such as reading, bingo and musical entertainment.
People had their medicines managed safely. Medicines were managed, stored, given to people as prescribed and disposed of safely. Staff were appropriately trained and confirmed they understood the importance of safe administration and management of medicines. Medicines Administration Records (MAR) were in place. People’s skin creams were kept in their rooms and people told us staff always applied their creams. However, the system in place meant the MARs were not always being completed to indicate people had their creams. The manager was going to look at ways this area could be improved. We saw this had previously been highlighted with staff.
Medicines were locked away as appropriate and where refrigeration was required, temperatures had been logged. We noted the temperature of the fridge was slightly higher than the recommended range and fed this back to the manager. People’s care plans indicated the precise area creams should be placed and contained information to inform staff of the frequency at which they should be applied. Staff were knowledgeable with regards people’s individual needs relating to medicines. For example, one staff member told us how one person struggled with their tablets so liquid medicine had been arranged for them. A few people managed aspects of their own medicine where they were safe to do so. No one at the service required covert medicine administration. Monthly audits monitored medicine management.
People told us they felt safe. Staff understood their role with regards the Mental Capacity Act (2005) (MCA) and the associated Deprivation of Liberty Safeguards (DoLS). Applications were made and advice was sought to help safeguard people and respect their human rights. All staff had undertaken training on safeguarding adults from abuse; they displayed good knowledge on how to report any concerns and described what action they would take to protect people against harm. Staff told us they felt confident reporting any incidents or allegations and these would be fully investigated.
Staff described the management as very open, approachable and “Very supportive.” Staff talked positively about their jobs. Staff worked together as a team to meet people’s needs for example covering additional shifts during the holiday season.
Staff received a comprehensive induction programme. The Care Certificate had not yet been implemented for new staff but the manager had all the information ready to start this with staff. The care certificate is a national initiative designed to ensure new staff are appropriately trained.
There were sufficient staff to meet people’s needs. The manager often covered shifts if required. Staff were appropriately trained, had a good deal of care experience as a team and had the correct skills to carry out their roles effectively.
There were effective quality assurance systems in place. Incidents were appropriately recorded and analysed. Audits were conducted, trends noted and action taken when needed. Feedback from people, friends, relatives and staff was encouraged.
People told us they had a choice of how they spent their day, including the time they got up and went to bed. We were told activities took place in the home and people said they chose whether to join in with these or not.
We observed the staff showed respect to people when they spoke with them; the atmosphere was calm, relaxed and friendly during our visit.
People who used the service told us they felt safe and the home had appropriate policies and measures in place to guard against abuse.
We found Pendrea to be clean and free of any offensive odours.
Medication practices were operated in a robust and safe manner.
The premises were in a good state of repair, well-furnished and a homely atmosphere existed.
Staff were supported by the senior staff and were provided with regular supervision and training.
People who used the service were consulted regarding the running of the home through daily conversations, quality monitoring surveys and regular 'resident's meetings'.