Background to this inspection
Updated
30 July 2021
The inspection
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.
As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.
Inspection team
The inspection was carried out by one inspector.
Service and service type
Pendleton Court Care Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.
Notice of inspection
This inspection was unannounced.
What we did before the inspection
We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report. We used all of this information to plan our inspection.
During the inspection
We spoke with four people who used the service and three relatives about their experience of the care provided. We spoke with eleven members of staff including the two area directors, the registered manager, the deputy manager, a registered nurse, a senior care worker, four care workers and the chef.
We reviewed a range of records. This included six people’s care records and multiple medication records. We looked at three staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.
After the inspection
We continued to seek clarification from the provider to validate evidence found. We looked at training data and quality assurance records. We contacted three professionals who regularly visit the service and contacted a further three relatives to gain their views.
Updated
30 July 2021
About the service
Pendleton Court is a care home which provides support for up to 58 people who require either; residential care, general nursing, or dementia nursing. At the time of the inspection there were 50 people living at Pendleton Court.
People’s experience of using this service and what we found
Staffing levels varied on different floors of the home. This led to some vulnerable people being left unsupervised on occasions. We have made a recommendation about deployment of staff throughout the home. Staff were recruited safely and all required documentation was in place.
Safeguarding issues were reported and escalated as required. Staff were aware of how to recognize and report any issues. Medicines were managed safely and staff had completed appropriate training.
Individual risks were assessed and monitored. Health and safety measures were in place to help ensure the safety of people using the service. We were assured infection control and prevention measures were appropriate and effective.
Care plans were person-centred and inclusivity was promoted within the home. Complaints were responded to appropriately and quality monitoring was regularly undertaken to help ensure standards remained good. The service engaged well with people who used the service, relatives and staff. People were encouraged to share their views within residents’ meetings. Relatives were kept informed of any incidents or news and staff attended meetings and one to one supervision sessions.
Learning was taken from the results of audits to help inform continual improvement to service provision. The home worked well with partner agencies and other professionals.
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 21 June 2019).
Why we inspected
We received concerns in relation to poor hygiene, poor staffing levels and poor care. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.
We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.
The overall rating for the service has remained good. This is based on the findings at this inspection.
We found no evidence during this inspection that people were at risk of harm from this concern. Please see the safe and well-led sections of this full report.
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 Pendleton Court Care Home on our website at www.cqc.org.uk.
Follow up
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.