We carried out a review of the data available to us about Pilgrims Way Care Home with Nursing on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Pilgrims Way Care Home with Nursing, you can give feedback on this service.
Pilgrims Way Care Home with Nursing (Pilgrims Way) is a residential care home providing nursing and personal care for up to 76 people. Since the service was registered there has been some reconfiguration of the space and as a result the service can accommodate 58 people. People's needs were varied and included people with high level nursing needs and some requiring to be cared for in bed. The service was arranged on two levels with an adjacent building called the Coach House linked via a covered walkway. At the time of our inspection there were 48 people using the service.
People’s experience of using this service and what we found
A new registered manager had been appointed since our last inspection and they had implemented some quality assurance processes, but these were not yet fully embedded within the culture of the service. Some elements of medicine management were not always safe.
People told us they felt safe living in Pilgrims Way. One person said, “I feel safe because the building is secure, there is always someone around and I am in the right place for the care I need.” Another person told us “I feel safe here, I don’t worry about anything. I was living at home, but I needed more help.” Relatives agreed that their loved ones were safe and happy.
People had comprehensive risk assessments and received care and treatment from staff who knew them well. There were enough staff with the right skills and training to meet people’s needs. Infection control was managed safely, and lessons were learned when things went wrong.
Most people told us the food was good and people’s dietary needs and preferences were met. People told us they had enough to eat and were given choices each day. Care staff and kitchen staff knew about any special diets and textures.
Recruitment was managed safely and there were enough staff deployed to provide safe care for people. Staff told us the registered manager was approachable and supportive.
People were involved in decisions about their care where possible and they received care which promoted their dignity and privacy. Some people attended activities they enjoyed when they could.
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.
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 13 December 2018.
Why we inspected
This inspection was prompted by a review of the information we held about this service and the length of time since the last inspection. As a result, we undertook a comprehensive inspection to review the five key questions of safe, effective, caring, responsive and well led.
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.
The overall rating for the service remains good.
Follow Up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.
Pilgrims Way Care Home with Nursing 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.
Pilgrims Way Care Home with Nursing is registered to provide accommodation and personal or nursing care for up to 76 older people. Accommodation is provided in two buildings that are joined by a covered walkway. There are well maintained gardens and off-road parking. The service is wheelchair accessible with passenger lifts between floors. At the time of our inspection one of the two buildings was under refurbishment and only one building was occupied. There were 43 people living at the service when we inspected.
At our last inspection on 15 March 2016 we rated the service good. The Safe domain had been rated as ‘Requires Improvement’ as a recommendation had been made regarding the lifting slings people used. At this inspection on 15 November 2018 we found the evidence continued to support the rating of good, the recommendation had been acted on and there was no evidence or information from our inspection and ongoing monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.
At this inspection we found the service remained Good.
There was a manager in post who had applied to the Care Quality Commission to become the registered manager, following our inspection the manager became the registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
People received a service that promoted their safety whilst promoting their rights and choices. Potential risks had been mitigated. People were protected from the risk of infection with appropriate control measures. The environment and equipment had been maintained to promote people’s safety.
People’s care and nursing needs were assessed prior to them moving into the service. People received consistent care from trained nurses and care staff. People’s specific health care needs were met with the support from health care professionals. Care records were comprehensive and reviewed on a regular basis.
People were supported to maintain their nutrition and hydration. The kitchen team ensured people had access to a variety of food choices. People that required additional support with their meals were catered for and supported in a safe way.
Nurses and care staff had been trained to meet people’s needs including their specialist needs. Staff received regular support and guidance from the management team.
People are supported to have maximum choice and control of their lives and staff support them in the least restrictive way possible; the policies and systems in the service support this practice.
People were treated with kindness and compassion. Staff understood the importance of promoting and respecting people’s privacy and dignity. People were supported to maintain their independence.
People were given the opportunity to raise and concerns or make suggestions about the service they received.
Systems were in place to monitor and improve the quality of the service.
Further information is in the detailed findings below.
At our previous inspection on 16 June 2015, we identified two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The breaches were in relation to safe recruitment and the management of waterborne infections. The provider sent us an action plan telling us how they would meet the regulations by 8 October 2016. Also, we made two recommendations for the provider to follow-up.
At this inspection, we found that the registered manager and provider had taken action to address the breaches and recommendations from the previous inspection.
The service provided accommodation, personal and nursing care for up to 76 older people. There were 42 people living in the service when we inspected. People predominantly needed nursing care to assist them to manage chronic and longer term health issues associated with aging or after an accident or illness. The accommodation was provided over two floors in a main building and a link attached extension. At the time of this inspection the 34 bedded link attached extension was not in use. A lift was available to take people between floors.
There was a registered manager employed at the service. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
Nursing staff assessed people’s needs and planned people’s care. They worked closely with other staff to ensure the assessed care was delivered. General and individual risks were assessed, recorded and reviewed. Infection risks were assessed and control protocols were in place and understood by staff to ensure that infections were contained if they occurred. However, it was not clear how staff were assessing and managing the risks posed to people by hoist slings sizes and how the potential risk of cross infection was controlled when slings were shared and stored together.
We have made a recommendation about this.
The provider and registered manager ensured that they had planned for foreseeable emergencies, so that should emergencies happen, people’s care needs would continue to be met. Equipment in the service had been well maintained. However, mattresses that relieved pressure on people’s skin were not always adjusted correctly.
The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care services. Restrictions imposed on people were only considered after their ability to make individual decisions had been assessed as required under the Mental Capacity Act (2005) Code of Practice. The registered manager understood when an application should be made. Decisions people made about their care or medical treatment were dealt with lawfully and fully recorded.
The registered manager had ensured that they employed enough nursing and care staff to meet people’s assessed needs. The provider had a dedicated system in place to assess people’s needs and to work out the required staffing levels. Nursing staff had the skills and experience to lead care staff and to meet people’s needs effectively.
People were supported to eat and drink enough to maintain their health and wellbeing. They had access to good quality foods and staff ensured people had access to food, snacks and drinks during the day and at night.
We observed safe care. Staff had received training about protecting people from abuse and showed a good understanding of what their roles and responsibilities were in preventing abuse. The registered manager responded quickly to safeguarding concerns and learnt from these to prevent them happening again.
Staff received training that related to the needs of the people they were caring for and nurses were supported to develop their professional skills maintaining their registration with the Nursing and Midwifery Council. (NMC.) Nursing staff received regular clinical supervision and support.
Incidents and accidents were recorded and checked by the registered manager to see what steps could be taken to prevent these happening again. The risk was assessed and the steps to be taken to minimise them were understood by staff.
People had access to qualified nursing staff who monitored their general health, for example by testing people's blood pressure. Also, people had regular access to their GP to ensure their health and wellbeing was supported by prompt referrals and access to medical care if they became unwell. Recruitment policies were in place. Safe recruitment practices had been followed before staff started working at the service.
There were policies and a procedure in place for the safe administration of medicines. Nursing staff followed these policies and had been trained to administer medicines safely.
We observed staff that were welcoming and friendly. People and their relatives described staff that were friendly and compassionate. Staff delivered care and support calmly and confidently. People were encouraged to get involved in how their care was planned and delivered. Staff upheld people’s right to choose who was involved in their care and people’s right to do things for themselves was respected.
If people complained they were listened to and the registered manager made changes or suggested solutions that people were happy with.
The registered manager of the service, nurses and other senior managers were experienced and provided good leadership. They ensured that they followed their action plans to improve the quality of the service. This was reflected in the changes they had already made within the service.
The inspection was carried out on 16 June 2015 and was unannounced.
The service provided accommodation, nursing and personal care for older people some of whom may be living with a secondary diagnosis of dementia. The accommodation was arranged over two floors. A passenger lift was available to take people between floors. There were 40 people living in the service when we inspected.
There was a person registered with the commission as manager on the day of our inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the service is run. However, on the day of the inspection the registered manager was no longer employed at the service, but the provider had appointed a new manager who was applying to register.
The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care services. Restrictions imposed on people were only considered after their ability to make individual decisions had been assessed as required under the Mental Capacity Act (2005) (MCA) Code of Practice.
Recruitment policies were in place. The manager ensured that they employed enough nursing and care staff to meet people’s assessed needs. Staffing levels were kept under constant review as people’s needs changed. However, the records kept when staff were recruited did not reflect safe recruitment practices.
The provider was not following published guidance about assessing and managing the risk of infections in care homes.
Managers ensured that they had planned for foreseeable emergencies, but the plans in place were not detailed enough to ensure that should an emergency occur, evacuation of the premises would be efficient and people’s care needs would continue to be met safely.
We have made a recommendation about this.
People’s care was responsive and recorded. Staff upheld people’s right to choose who was involved in their care and people’s right to do things for themselves was respected, but care plans were not individualised.
We have made a recommendation about this.
Audits were taking place to assess the quality and safety of the service, but these were not covering all aspects of the service which had resulted in some areas being missed.
Staff received training that related to the needs of the people they were caring for and nurses were supported to develop their professional skills. However, staff were not receiving supervisions or appraisals in line with the providers policy.
The manager and care staff assessed people’s needs and planned people’s care to maintain their safety, health and wellbeing. Risks were assessed, recorded and reviewed. However, when nurses reviewed care plans they had not always recorded that there had been a change in a person’s needs when they recorded their review notes.
People felt safe. Staff had received training about protecting people from abuse and showed a good understanding of what their roles and responsibilities were in preventing abuse. The manager responded quickly to safeguarding concerns.
Incidents and accidents were recorded and checked by the manager to see what steps could be taken to prevent these happening again. The risk in the service was assessed and the steps to be taken to minimise them were understood by staff.
People had access to qualified nursing staff who monitored their general health, for example by testing blood pressure. Also, people had regular access to their GP to ensure their health and wellbeing was supported by prompt referrals and access to medical care if they became unwell.
There were policies in place for the safe administration of medicines. Nursing staff followed these policies and had been trained to administer medicines safely.
People and their relatives described a service that was welcoming and friendly. Staff provided friendly compassionate care and support. People were encouraged to get involved in how their care was planned and delivered.
Staff supported people to maintain their health by ensuring people had enough to eat and drink.
If people complained they were listened to and the manager made changes or suggested solutions that people were happy with.
People told us that managers were approachable and listened to their views. The manager of the service, nurses and other senior managers provided good leadership. They ensured that they followed best practice for people living with dementia and associated health problems.
We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we have taken at the back of the full version of the report.
We spoke with a relative who was visiting the home. They told us they were pleased with the way their family member was cared for. They said, “I have been really pleased with everything here. The staff are very good. It always smells fresh and clean”.
During this inspection we found that people or their representatives were asked for their consent before any care and treatment was given.
People were provided with appropriate care and support that met their needs and promoted their wellbeing.
People received the medication they needed at the time they needed it.
Staff received the training they needed to enable them to provide appropriate care and treatment.
People knew who to talk to if they had any concerns about the service and were confident they would be dealt with.
Another person, who moved to Pilgrims from another home six months ago, told us 'I have never been happier, I am very well looked after here'.
People who were using the new dining area said they liked it. They said the home was kept clean and they liked their rooms.
People who were using the new dining area said they liked it. They said the home was kept clean and they liked their rooms.
People living at the home told us that they were satisfied with the care and support they received. They said that staff were kind and caring, were respectful and there were enough staff on duty.Comments included 'Carers are very kind and helpful 'and 'The bell is answered quicker than it used to be'. People told us they liked the food at the home and activities were provided. One person who preferred to spend most of the time in their room said they felt rather isolated and wished staff had more time to spend with them.
People who were using the new dining area said they liked it. They said the home was kept clean and they liked their rooms.
People told us that the food was good and there was always a choice. One person said 'I asked for curry to be put on the menu and we're having curry today, I love curry.'
People had access to health care such as dentists, doctors and district nurses. Overall the home was clean and tidy. Some areas of the home were newly refurbished but a few areas were in need of refurbishment/redecoration. A development plan to improve the environment was in place.
Pilgrims Way was registered under the Health & Social Care Act in October 2010 (previously registered under the Care Standards Act) with no conditions of registration. Since the last inspection a new manager has been appointed and had been in post for four days before we visited. The newly appointed manager was confidently able to describe to us the areas of the service that need to be improved.