Pendle Brook Care Home

Updated 14 September 2022

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 Health and Social Care Act 2008.

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 three inspectors.

Service and service type

Pendle Brook Care Home is a ‘care home.’ People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Pendle Brook Care Home is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. 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.

At the time of our inspection there was not a registered manager in post. However, the manager was in the process of registering.

Notice of inspection

This inspection was unannounced.

Inspection activity started on 20 June 2022 and ended on 30 June 2022. We visited the service on 20 and 22 June 2022.

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 who work with the service. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with six people who used the service and two loved ones about their experience of the care provided. We spoke with eight members of staff including the manager, deputy manager, operations manager, senior care workers, care workers and the area manager (who is also the nominated individual). The nominated individual is responsible for supervising the management of the service on behalf of the provider. We reviewed a range of records, which included detailed reviews of three people's care plans and various medication records. We looked at five staff files in relation to recruitment. A variety of records relating to the management of the service, including policies and procedures were reviewed.

Updated 14 September 2022

About the service

Pendle Brook Care Home is a care home without nursing care, providing accommodation for persons who require personal care for up to 50 people. The service provides support to adults and older people and people living with dementia. At the time of our inspection there were 29 people using the service. The care home can accommodate people across three floors in one building, however at the time of our inspection, only two floors were being used.

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

Medicines and risks relating to people's health and safety were not always being appropriately managed. Staffing levels were adequate and recruitment practices were robust. Safeguarding practices were in place; staff knew what to report and people living at the home told us they felt safe. Good infection prevention control practices were being followed and people were receiving visitors. Accidents were recorded and lessons were learned.

People's needs were not always fully assessed, and people's care plans did not always detail necessary information. Staff were supported through supervisions, though staff training was not fully up to date. We have made a recommendation about staff training. Feedback on meals indicated improvements were needed. Although the home was purpose built, the environment could be improved for people living with dementia. Oral healthcare plans were in place and the home was registered with a dental hygienist. The service worked in partnership with a variety of health care professionals.

People were not always supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests. Although the policies and systems in the service supported this practice and necessary DoLS referrals were being made, best interest decisions were not always in place. We made a recommendation the provider ensures they follow best interests’ guidance.

People's equality, diversity and dignity was respected. The service used an electronic care plan system to record people’s details on. People and their relatives were able to express their views. Surveys were being completed to gather feedback and people were able to access advocacy if required.

Records relating to people’s care were not always person centred, but people were able to make everyday choices. There was a complaints policy and procedure in place and a complaints log was being maintained. At the time of the inspection no one was in receipt of end of life care. People’s communication needs were being met. An activities coordinator was employed by the provider who led on a variety of activities for people living in the home.

Quality assurance systems needed further improvement. Various documents were either not completed, not in place, not up-to date or not accurate and audits carried out by the manager did not always identify the issues we found at this inspection. Staff were aware of how to report poor practice and there was a procedure in place to support this. Feedback about the manager was positive. The manager reported necessary incidents to appropriate organisations and lessons were learned. Meetings for staff and people that use the service were taking place, and relatives were kept up to date via telephone, email and through social media. Surveys were available for staff, people and their relatives to complete.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (3 November 2021). The service remains rated requires improvement. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider remained in breach of regulations.

At our last inspection we recommended that provider reviews, their processes to ensure safe recruitment practices are always followed. At this inspection we found the provider had acted on this recommendation and improvements had been made.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

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 see what action we have asked the provider to take at the end of this full report. The provider is working in making improvements in the areas we have identified.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Pendle Brook Care Home on our website at www.cqc.org.uk.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to risk, medication and governance at this inspection.

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

Follow up

We have met with the provider to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.