Archived: Pelham House

Updated 15 March 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.

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 2 inspectors, a medicines inspector and Expert by Experience. 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 Expert by Experience spoke with people’s relatives.

Service and service type

Pelham House 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. Pelham House is a care home without nursing care. The Care Quality Commission (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 CQC 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 an application had been submitted.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

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 reviewed information received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used all this information to plan our inspection.

During the inspection

We spoke with 6 people living at Pelham House, a visitor and 9 relatives about their experience of the care and support provided. We spoke with 4 care staff, the deputy manager, operations manager and quality and compliance officer. We spoke with the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We reviewed 4 people’s care records. We reviewed 8 medicine administration records. We observed medicines administration and spoke to a member of staff who was trained to administer medicines.

Updated 15 March 2023

About the service

Pelham House is a residential care home providing care and support to up to 22 people, some of whom were living with dementia. At the time of the inspection there were 15 people living at the service.

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

At this inspection we identified concerns with the oversight and governance, the environment – in particular the heating and hot water provision, and the training of staff. Further areas for improvement around the management of medicines were identified.

People, their relatives and staff commented that the heating and hot water were not always working. People told us they were sometimes cold.

Checks and audits were not consistently effective. Shortfalls found during the inspection had not been identified through the service’s checking processes. When shortfalls had been identified, follow up actions had not always been taken to ensure these were addressed.

Staff training had not been completed or refreshed as required. There was a lack of oversight of staff training needs.

Accidents and incidents were recorded, and people had been referred to health care professionals when needed. However, there was no overview of these to ensure any patterns or trends could be identified. The quality and compliance officer provided this during the inspection.

Risks to people’s health, safety and well-being were assessed and measures were in place to reduce risks to people. Some risk assessments required further development.

People received their medicines safely. We identified some areas for improvement with the medicines management to ensure the service followed best practice.

People were supported by enough staff who had been recruited safely. People told us they felt safe living at Pelham House and their relatives told us they were generally cared for well. A relative said, “[My loved one] is treated with kindness. Staff always give them time and are patient.”

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 told us they enjoyed their meals and they were offered choices. People were supported to see health care professionals, such as chiropodists and dentists, as needed.

People were supported by staff who were patient, kind and caring. Staff knew people and their needs and preferences well. People were able to participate in various activities and there were links with the local community, such as local school children visiting.

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 inadequate (published 24 October 2022). There were breaches of regulation and the service was placed into Special Measures. This service has been in Special Measures since 24 October 2022.

At this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures. However, we identified breaches of regulation. The service has been rated requires improvement or inadequate for the last five inspections, where a rating has been given.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection. We have found evidence that the provider needs to make improvements. Please see the safe, effective, and well-led sections of the report.

Enforcement

We have identified breaches in relation to staff training, the environment and good governance at this inspection.

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

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.