Pondsmead Care Home

Updated 30 November 2023

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.

This was a targeted inspection to check on concerns we had about staffing and medicines management.

Inspection team

The inspection was carried out by 3 inspectors, one of whom was a specialist medicines inspector.

Service and service type

Pondsmead 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. Pondsmead Care Home is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager.

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was not a registered manager in post. However, a manager had been appointed and they had begun the process to be registered with the Commission.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We looked at the information we had received from and about the home.

We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make.

We used information gathered as part of monitoring activity that took place on 28 June 2023 to help plan the inspection and inform our judgements.

We used all this information to plan our inspection.

During the inspection

During the inspection we spoke with 11 people who lived at the home and 7 members of staff. The provider's general manager and assistant general manager were available throughout the day.

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 looked at some records. These included, 2 staff recruitment files, a sample of medicines administration records, audits of medicines and minutes of meetings.

Updated 30 November 2023

This inspection took place on 7 and 8 August 2018 and was unannounced.

Pondsmead Care Home was last inspected in July 2017 and was rated requires improvement. We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and one breach of the Care Quality Commission (Registration) Regulations 2009.

At the last inspection we found there were insufficient staff to meet people’s needs in a safe and timely manner. We also found that following an independent review of fire precautions some work needed to bring the fire precautions to the recommended standard had been completed. However, there remained areas, including one which had been identified by the review as "significant", which had not been completed. We also found records had not always been completed accurately to reflect how and when care had been provided to people in the home. The systems in place to monitor the quality of the service provided had not identified the shortfalls found in the inspection. The provider sent us an action plan setting out how and when they would be compliant.

At this inspection we found there had been an improvement in all areas of care and support provided in the home. However, there was still work needed to maintain the improvements consistently. We found that there was an inconsistency with the recording in care plans between the residential unit and the nursing unit. The residential unit care plans were person centred with sufficient guidance for staff to follow. However, the care plans on the nursing unit were more generalised and less person centred. Staff on the nursing unit had failed to record interventions in the correct forms. These shortfalls had been identified by the registered manager and training and one to one supervision had been put into place. This meant the systems in place to identify shortfalls and drive improvement were more robust and had been used effectively.

There were sufficient staff to support people in a safe and timely manner a reorganisation of the home so that people with non-nursing needs were cared for on one floor meant staff were deployed more effectively. Staff spoken to said they had more time to spend with people and less “running up and down stairs.”

The first day of the inspection was carried out by one adult social care inspector, a specialist nurse advisor (this is a person who provides specialist advise during the inspection on general nursing) and an expert by experience and was unannounced. An expert-by-experience is a person who has personal experience of using or caring for someone who uses this type of care service. The second day was carried out by one adult social care inspector and a specialist nurse advisor and two assistant inspectors and was announced.

Pondsmead 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.

All the work required to bring the fire precautions up to the recommended standard had been completed and fire precautions in place in the home were found to be safe.

The administration of medicines was managed safely however it was noted that one person’s pain management care plans had not been developed following their initial assessment. The registered manager had identified that staff were recording pain management in daily records and not the specific form. training had been arranged for all staff in the correct way to use the electronic system.

People said the standard of food in the home was good, one relative said they were happy to see their loved one eating a healthy well-balanced diet. There were choices available on a seasonal menu and people could request an alternative if they did not like the food on the menu for the day. The dining experience for people was relaxed and a social occasion. However, we saw the dining room was laid up to a high standard during the morning but when meals were served people did not have the benefit of the tablecloths and cotton napkins which were removed. We discussed this with the registered manager who told us this did not usually happen and people usually had the benefit of a napkin and tablecloth. We saw the routine had changed on the second day of the inspection with the tablecloths remaining on the table and condiments provided. One person spoken with said, “The new owner likes it to look like that during the day.”

People told us they felt safe living in the home. One person said, “I feel very safe living here.” A relative said, “I am happy [the person] is safe. They were falling over at home and they haven’t fallen once since they have been here.”

There were systems and processes in place to minimise risks to people. These included a robust recruitment process and making sure staff knew how to recognise and report abuse. All staff spoken with were confident action would be taken by the registered manager and provider to address any issues they may raise.

People received effective care from staff who were well trained and understood their needs, likes and dislikes. People told us they felt staff were well trained and that they knew their care needs, likes and dislikes.

People said they received care and support from caring and kind staff. Comments included, “They [the staff] are all really nice and friendly.” And, “They [the staff] are all lovely.” And “There is always a cheerful and happy group of staff.”

People told us they could talk with staff and the manager if they wished to raise a concern. One person said, “He [the registered manager] is always about the home and takes the time to listen to you.”

People were supported at the end of their life to have a comfortable pain free death. Care plans showed people’s advance decisions were taken into consideration and acted upon. The staff also supported the bereaved with compassion understanding.

There was a clear drive to improve the service and the quality of care provided. This could be seen at all levels of staff who told us they were proud of the changes they had made and the plans for the future development of the home.