Pendlebury Court Care Home

Updated 13 March 2020

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.

Inspection team

The inspection was completed by two inspectors.

Service and service type

Pendlebury Court is a ‘care home’. People in care homes receive accommodation and 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. The registered manager was not available on the day of inspection as they were on leave.

Notice of inspection

The 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. We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all of this information to plan our inspection.

During the inspection

We spoke with three people who used the service and six relatives about their experience of the care provided. We spoke with seven members of staff including a care consultant, senior care workers, care workers and the cook. We spoke with five visiting health professionals. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We reviewed a range of records. This included four people’s care records and two people’s medication records. We looked at two staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including accident and incident analysis and quality assurance records were reviewed.

After the inspection

We reviewed documentation the care consultant sent to us to validate the evidence found. We continued to seek clarification from the provider to validate evidence found. We looked at training data and actions taken following feedback at inspection.

Updated 13 March 2020

About the service

Pendlebury Court Care Home is a residential care home for up to 39 people which provides accommodation and personal care to older people in one adapted building. The building has two floors with communal areas on each. At the time of our inspection there were 36 people living there.

People’s experience of using this service and what we found

Risks to people’s health and wellbeing were not always assessed to ensure their needs were met in a way that protected them from harm. Learning did not always take place to ensure lessons were learnt. People received their medicines as prescribed, however the provider did not always ensure relevant guidelines were followed around storage of medicines.

People’s needs were not always assessed to ensure their needs were met by effectively trained staff. People were not always involved in meal planning and did not always have regular access to drinks throughout the day.

Governance systems were not always effective in identifying areas where quality and safety of care had been compromised.

People were not always supported to follow interests or social activities. We have made a recommendation about providing person-centred activities.

People were not always supported in a meaningful way by staff.

People were not always involved in care reviews and this practice was inconsistent. People’s communication and information needs were not consistently met. People felt able to make a complaint and felt this would be investigated, however this was not always recorded.

People were supported to have independence and make choices. There were enough staff to ensure that people's needs were met safely. People were protected from abuse and people told us they felt safe. Practices were in place to ensure prevention and control of infection protected people.

People received good outcomes for their health and wellbeing. Staff worked well with other health and social care professionals to achieve this. People were supported in an environment suitable for their needs.

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.

People’s privacy and dignity was respected. People and their relatives felt the staff were helpful and kind when interaction did occur.

Staff knew how to work with other professionals to ensure people had a comfortable and dignified death.

People, relatives and staff knew who the registered manager was and felt they were approachable. People, their relatives and visiting health and social care professionals were invited to give feedback and the provider then used this information to inform changes. The provider was transparent, open and collaborative with external agencies.

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 11 June 2018).

Why we inspected

The inspection was prompted due to concerns received about activities and staffing. A decision was made for us to inspect and examine any risks.

We have found evidence that the provider needs to make improvements. Please see the key question sections of this full report.

Enforcement

We have identified three breaches in relation to person-centred care, safe care and treatment and quality assurance at this inspection.

Please see the action we have told the provider to take at the end of this report.

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.