Pendleton Court Care Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. Staff told us management were a visible presence in the home, were approachable and staff felt comfortable speaking with them and raising concerns. Staff also said they felt supported by managers. Comments included, “I love working here. I am able to speak to any of the seniors or managers”, “I feel able to raise concerns and am well supported” and “I could talk to any of the managers, they are very professional, approachable and supportive.” Relatives also spoke positively about how the home was run and communication with and by management. One stated, “We could ask anything in the office [where management are based], anytime and they would always give us an answer, chat with us. Nothing has ever worried us about the home.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The provider had up to date whistleblowing / speaking up policy and procedures, which were regularly reviewed. These were readily available to staff, being both on display within the home and available electronically. When asked, staff were able to explain what they would do if they needed to escalate concerns.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. An audit calendar was in place which detailed what checks and monitoring was completed on a monthly and quarterly basis. Each month auditing was completed of medicines, care files, diabetes management and dining experience. Quarterly audits covered catering, falls, moving and handling, choking, and infection control. From reviewing records, we found audits had been completed consistently. Aside from some of the medicines issues we noted, audits had been successful in identifying shortfalls and supporting improvements. Other governance processes were in place to support the monitoring of care delivery and ensure people’s experiences were positive. These included person of the day, daily walk rounds by management and out of hours visits, again by management. Any issues noted from these processes was added to the home’s improvement plan and shared with the provider. The provider had ongoing oversight of the home, with both the area director and regional quality improvement lead monitoring audit and governance processes, but also completing their own checks to ensure the provider remained compliant with regulations. We found record keeping overall to be accurate and contemporaneous. When checking people’s care plans, we did identify some minor errors and inconsistent information. However, this was addressed timely following verbal feedback to the provider.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research. An overarching action plan was used for capturing any actions or issues noted from audits and governance processes. This listed the area for improvement or action, who it had been assigned to, date when needed to be completed, section for updates and links to evidence to demonstrate the action taken and improvements made. The provider also used a quality review and improvement dashboard, which was an electronic process for monitoring a range of areas, with graphs used to detail patterns and trends, for example, number of falls, infections or unplanned weight loss over last 12 months. Learning meetings were held every month, attended by management and heads of department e.g. catering, housekeeping and maintenance. These meetings was used to review issues, incidents and compliance, discuss any required actions and share lessons learned.