Pilgrims Way Care Home with Nursing

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to inadequate.

This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to people’s safe care and treatment and the ways people’s medicines were managed.

This service scored 31 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

Incidents were not well recorded and were not always well managed. This increased the risk of harm to people. For example, some people had become upset or distressed. There was no clear plan in place to support staff to help people when they were upset. One person was now prescribed medicine to support them to remain calm. Whilst they did have a positive behaviour support plan in place the information it included was limited and generic. For example, the care plan instructed staff to use distraction and redirection but did not include what had or had not worked for the person previously to distract and redirect them. Staff had not undertaken positive behaviours support training, and we were not assured staff had been given the tools they needed to manage incidents between people or support people when they were upset.

Care plans did not always include information about mitigation in place to reduce incidents such as falls. For example, one person had a risk assessment in place following a fall. There was no information on what mitigations were in place to reduce the risk to the person from future falls. The person had an alert mat in place, so staff knew if they’d got out of bed. However, this was not mentioned in the care plan to provide staff with guidance on its use.

Incident forms were not fully completed. There was a system in place to record incidents and support management to analyse them. However, this was not being utilised and parts were left blank. For example, where the incident occurred or what triggered the incident. Incidents and accidents were not always reviewed for trends. For example, there were 9 falls in June and July and no analysis of trends had been completed to understand if there were opportunities to improve safety and learn lessons.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

The lack of information about people in their care plans meant information about people would not be shared when records were passed on, for example if people moved to another service. Concerns were not always shared with CQC or the local authority when they should have been. However, the service did work alongside other services to provide support to people and people were referred as needed. For example, people had access to occupational therapists and mental health team. Staff from the local GP surgery visited weekly to provide clinical support to people and address people’s healthcare needs.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

People were not being well protected from the risk of abuse. Concerns, which should have been reported to the local authority and CQC as safeguarding concerns were not. This meant people were denied protection and independent scrutiny. For example, a safeguarding had not been raised when one person had assaulted another or when there had been unsolicited physical contact by one person towards another. People’s care plans had not always been updated following incidents to ensure there was a good plan to reduce the risk of further safeguarding concerns arising.

Staff had not all completed safeguarding training in adults or children. However, staff were able to tell us who they would report concerns to. The service had a safeguarding policy in place. However, the contact information for the safeguarding lead at the service was incorrect.

Some people had deprivation of liberty authorisations (DOLs) in place or applications had been submitted for these. The registered manager told us they were not certain everyone who needed a DOLs had been reviewed and an application submitted as people’s needs changed. They were in the process of reviewing people’s care and support to assess this in line with recent changes to when a DOLs application was needed.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risks to people had not been well managed. For example, when people were constipated there was no evidence they were being effectively supported to manage this risk. Records showed one person had not been noted to have had a bowel movement for 7 days. There was no evidence they’d been offered a laxative or other measures to address this.

Where people had diabetes care plans were mainly generic and needed improvement to ensure they reflected individual’s needs. One person’s blood sugar was high at times, and their care plan did not include this information about the person’s diabetes. When their blood sugar was found to be high there was no evidence staff were checking back later to see if it had sufficiently lowered. Staff recorded how much fluid they offered people. There was no evidence the person was offered more fluid on the days their blood sugar was high to help reduce this. Kitchen staff had not undertaken training in how to support people with diabetic diets and were preparing food for people who were diabetic. They told us people with diabetes were offered healthier alternatives. However, we found there was still room for improvement and risks were not being well mitigated.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

Risks to people from the environment were not always well managed. One person’s door had a sign attached warning staff not to close the door because it could not be re-opened from the inside. Staff told us this had been the case for 2 weeks and the person’s door was left open at night which impacted on their dignity and privacy. We asked the provider to fix this immediately as there was a risk to staff and people in the event of a fire.

We also identified a shower hoist which had not been safety checked when it needed to be. We found doors were left unlocked such as the door to the sluice room, laundry room and cleaning chemicals. One shower room had a full-length mirror which was propped up against the wall and not secured. The emergency cord in one bathroom was tied up and out of reach meaning if a person fell, they would not be able to pull the cords as an alarm. We also found thickener was in an upstairs kitchen which was left unlocked and accessible. Thickener can be harmful if ingested unprepared as it can block a person’s airway and cause them to choke.

Fire drills were undertaken. However, these did not include practicing evacuation and some staff fed back they were not confident evacuating people in the event of an emergency. One staff told us they did not know how to use evacuation equipment. Another told us they were not sure of the procedure. We raised this with the provider and asked this be addressed immediately after the inspection visit.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

There was enough staff to support people. However, some people were unhappy with how staff were deployed and feedback about the response to call bells was mixed. One relative told us, “[My relative] will press the button and has to wait for [their] dedicated carer, by this time [they are] to get out of bed, [they are] getting annoyed, it’s hit and miss, it’s not every time, but we grab hold of anybody now.”

The service regularly used agency staff to support permanent staff. Managers told us people were happy with the agency staff who supported them. However, we found this was not always the case. One relative told us, “There seems to be a high turnaround of temporary staff, they have a lot of agency staff. All I would say is that the staff all know the residents and their quirks, perhaps the agency staff are not quite as invested.” One person said, “Senior ones know what I need, agency don’t.” One staff told us, “The number of staff we have each day is great. Yes, we do need to use agency sometimes, some are better than others.” Another said, “We rely too heavily on agency staff.”

Staff had not undertaken the training they needed to support people. There were significant gaps in training which needed to be addressed to ensure staff had the knowledge and skills they needed to provide people with effective support. For example, staff had not completed training in supporting people who were distressed and upset. Some staff had not completed training in supporting people who were diabetics or people with learning disabilities and autistic people which is a requirement for staff in care homes who may come in to contact with people who have these support needs. Staff have also not all completed training in end-of-life care, first aid or safeguarding.

Recruitment checks had been carried out to ensure that staff were recruited safely. For example, to make sure Disclosure and Barring Service (DBS) checks had been completed. DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Some people living at the service had a raised risk from a transmittable infection. There was also an increased risk of transmission to other people due to this. Staff were not aware of this risk and therefore could not take steps to protect themselves and other people. Information had not been shared with staff to enable them to understand the increased risks. There was no plan in place to reduce the risks if a person did become unwell.

For the most part the service was clean. One relative told us, “It’s very clean and always really tidy.” However, there were some areas such as some shower floors that needed to be deep cleaned or replaced.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

The service had systems and processes in place to support the safe management of medicines however, staff were not always following these. Temperature monitoring checks were completed. These were in range and staff knew what to do if they were out of range. Medicines which required extra security were audited weekly and signed by two members of staff. However, they were not being destroyed safely or according to the provider policy.

People were not always receiving their medicines as prescribed. We identified concerns regarding medicines supply management. One person had missed prescribed medicines for two consecutive nights because the service had run out of stock and a prescription had not been issued. This led to the person experiencing side effects from not having their medicine. Staff had not followed processes for ensuring the medicine was in stock, also a medicine stock discrepancy was identified which could not be immediately explained. We could not be assured there was a robust system in place to identify when medicines were running low or unavailable.

People who were prescribed medicines with special administration instructions were not always receiving their medicines correctly. One person was prescribed a medicine which needed to be given 30 minutes before food or any other medicines. Records showed the medicine was administered at the same times as other medicines which can stop the medicine working properly, placing the person as risk of the condition not being treated correctly.

Records did not contain personalised information about how people preferred to take their medicines. Staff may not have sufficient information to support people in a person-centred way and risked medicines being administered differently by different staff members.

Medicines were administered with care and compassion and staff followed appropriate infection prevention practices. Staff had received training and competency assessments to administer and manage medicines.

No 'as required' (PRN) medicines protocols were in place. There was insufficient documented information about when PRN medicines should be administered, expected outcomes, and when to seek further medical advice. This put people as risk of uncontrolled symptoms or side effects. For example, there was no guidance to support staff in identifying when PRN medicines for constipation should be administered or when concerns should be escalated. This put people at risk of complications such as impaction or bowel obstruction.

Records showed information to support in the administration of high-risk medicines, for example blood thinning medicines and insulin. Medicines are considered time critical if a delay could lead to a person becoming unwell. We saw evidence of a time critical medicine given at the correct time, and medicated patches were being applied in line with manufactures instructions.

There were no appropriate flammability risk assessments and guidance available for paraffin-based topical preparations. These transfer onto clothing, bedding and bandages resulting in a fire risk and we were not assured that staff were able to keep people safe from serious injury.