Pelsall Hall

We found the following examples of good practice.

¿ Staff, relatives and healthcare professionals were required to follow strict processes when entering the home to prevent the introduction of infection.

¿ A nominated relative could book a slot to visit their family member in line with the new Government visiting directive.

¿ The use of single occupancy bedrooms, social distancing and where possible good ventilation reduced infection risk.

¿ Systems in place ensured people would be admitted safely to the home to prevent the risk of infection entering into the home.

¿ Stocks of Personal Protective Equipment (PPE) were ample for staff, visitors and people to use.

¿ COVID-19 tests were carried out three times a week for staff and monthly for people to identify if there were any COVID-19 cases.

¿ The premises offered a number of communal rooms and bedrooms were single occupancy with wet room facilities. This helped to promote social distancing and reduce a risk of infection transmission within the home.

¿ Robust cleaning regimes ensured the risk of infection transmission was reduced.

¿ Staff received IPC training which included donning and doffing of PPE and PPE usage.

¿ The provider's IPC policy had been reviewed regularly.

Pelsall Hall is a residential care home providing personal and nursing care to 37 people aged 65 and over at the time of the inspection. The service can support up to 41 people.

The home is a purpose built building with communal spaces and bedrooms laid out over three floors.

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

People gave us consistently good feedback during our inspection. Typical comments included, “The food here is perfect, they over indulge us,” and “My room is lovely and I can’t fault anything about this house.” Relatives were equally positive and staff told us how much they enjoyed working in the home. One relative said, “I cannot fault anything here; my relative is so happy, they are well looked after and are looking twenty years younger!”

People felt safe and there were enough experienced and suitable staff to meet people’s needs. Medicines were well managed, and people were protected from the risk of infection and harm.

The service worked well in partnership with other professionals to make sure people stayed healthy. 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.

Staff treated people with care and respect and ensured that people retained their independence as much as possible. People were given choices and staff knew how to communicate with people.

People enjoyed a varied activities programme that was based on their interests and hobbies and enabled people to feel a part of their local community. Care and support was personalised and organised to meet the needs of the people who lived in the home.

The service was well-led and the new manager had had a positive impact on the quality of the service. People, relatives and staff felt engaged in the running of the home and the provider gave managers good support to make any changes that were required.

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 05 January 2017).

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Pelsall Hall is a care home that provides accommodation and personal care for up to 41 people. There were 39 people living at the home on the day of our inspection.

There was a registered manager in post at the time 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 legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At our last inspection on 17 February 2016, we found breaches of Regulations of the Health and Social Care 2008 (Regulated Activities) 2014. We gave the service an overall rating of requires improvement. These breaches related to the provider’s failure to protect people from the risk of harm, consistently meet people’s nutritional needs or establish robust quality assurance systems. The provider sent us an action plan setting out the improvements they intended to make.

At this inspection, we found the provider had made significant improvements to the service. They had taken steps to protect people from harm and abuse. Staff had been given training in, and understood, how to recognise and report abuse. The risks associated with people’s care and support needs had been assessed and plans put in place to manage these. The provider assessed and organised their staffing requirements in order to meet people’s individual needs. People received their medicines safely from trained staff.

Staff had the necessary skills and knowledge to meet people’s needs and to communicate with them effectively. The provider protected people’s right under the Mental Capacity Act 2005. People had the support they needed to eat and drink. Staff monitored people’s health and helped them to access healthcare services.

Staff adopted a caring approach towards their work and knew the people they supported well. The provider encouraged people’s involvement in care decisions that affected them. Staff treated people with dignity and respect.

People received care and support that was shaped around their needs and preferences. People and their relatives knew how to complain, if they were unhappy with any aspect of the service provided.

The provider promoted an open and inclusive culture within the service. People and their relatives felt the provider took their views into account. Staff felt well supported and able to challenge working practices. The provider made use of quality assurance systems to drive improvement at the service.

Pelsall Hall is a residential home that provides personal care and accommodation for up to 41 older people, many of whom are living with dementia. At the time of the inspection there were 39 people living at Pelsall Hall. Six of these people were living in a specialist dementia unit at the service called Eden Rise. A registered manager was in post. 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 felt safe living at the service and were protected by a staff team who could recognise signs of potential abuse. Staff knew how to report any concerns about people and were confident in ‘whistle blowing’ if this was ever required. People were put at risk of injury due to unsafe moving and handling practices. Accidents and incidents were not consistently recorded and reported to managers. People were not always supported by sufficient numbers of staff, in particular at meal times. People received their medicines as prescribed.

People were supported by staff who had access to regular training, however their competency in their role was not assessed. Some staff members did not always demonstrate the skills required to support people effectively. Decisions about people’s care were not always made in line with the Mental Capacity Act 2005 when people lacked mental capacity. People did not always receive the support they needed to meet their nutritional needs.

People were supported by staff who were kind and caring. People were made to feel valued and were supported to make choices about their day to day care. People’s privacy, dignity and independence were protected and promoted. People were supported to maintain relationships that were important to them.

People were not protected by effective quality assurance systems. Systems did not identify all issues and areas of risk within the service. People spoke highly of the management team within the service. People, their relatives and staff all felt involved in the development of the service and had confidence in managers to make any required improvements.

We found that the provider was not meeting all of the requirements of the law. You can see what action we told the provider to take at the back of the full version of the report.

We looked at records, spoke with staff, visitors and people who lived at the home to find out about the food available to them. We were told that the food was good and that there was plenty of it. We observed the lunchtime meal being served and saw that people had a choice of food and drink. Records showed that people's likes and dislikes had been recorded and that satisfaction surveys were used to check that people were happy with the quality of the food served.

We looked at the storage and management of medication. A senior carer explained the systems in use which appeared to be robust and made audit of medication easy.

There were 38 people living at the home at the time of our visit. We spent some time in the lounge observing the interaction between staff and people who lived at the home. We saw staff spending time chatting to people and singing and dancing with them. Everyone that we spoke with praised the staff. One person commented: "(My relative) has excellent care, it is the best place ever, a wonderful service, it's like a four star hotel". Another person said: "All of the staff are friendly and chat with you".