Archived: Pilgrims Lodge Residential Home

Updated 11 July 2017

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on the 4 and 5 May 2017 and was unannounced. The inspection was conducted by one inspector and one expert by experience. The expert by experience had personal experience of caring for older people living with dementia.

Before our inspection we reviewed information we held about the service, including previous inspection reports and notifications. A notification is information about important events which the service is required to tell us about by law. We reviewed the Provider Information Return (PIR) and used this information when planning and undertaking the inspection. The PIR is a form that asks the provider to give some key information about the service, what the service does well and what improvements they plan to make.

During the inspection we spoke with three people, two visitors, four staff, the deputy manager, a registered manager from the providers other service and the provider. After the inspection we received feedback from one healthcare professional.

Not everyone was able to verbally share with us their experiences of life at the service; this was because they were living with dementia. We carried out a Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experiences of people who could not talk with us.

We looked at a variety of documents including four peoples support plans, risk assessments, daily records of care and support, three staff recruitment files, training records, medicine administration records, and quality assurance information.

Updated 11 July 2017

This inspection took place on the 4 and 5 May 2017 and was unannounced. Pilgrims Lodge Residential Care Home provides accommodation and support for up to 26 older people, some of whom are living with dementia. At the time of our inspection 21 people were living at the service.

The previous inspection on 17 March 2015 found no breaches of our regulations although one recommendation was made about ensuring that everyone’s safety was taken into consideration when leaving the building in the event of a fire, an overall rating of good was given at that inspection. Although the provider had taken action in response to the recommendation made, further improvement was required around processes should the service need to respond to an emergency situation.

The accommodation is divided into two main living areas and people are free to choose where they wish to spend their time. Both areas have separate lounges and dining areas and there is a small kitchen available where people are able to get drinks and snacks.

The registered manager had de-registered with the Commission in December 2016. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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. The service was being overseen by the deputy manager; the provider had not taken appropriate action to employ a new registered manager which is a requirement of their registration.

People were not protected by robust recruitment procedures, the provider could not demonstrate how they ensured the staff they employed were suitable for their roles.

The provider had not developed any contingency plans should there be a disruption in the delivery of the service or if there was an emergency situation. People did not have adequate individual personal emergency evacuation plans (PEEPs) that staff could refer to in emergency evacuations.

Medicine was not robustly monitored or audited to ensure all medicine was accounted for. Not all areas of the service were clean or well maintained, some people’s duvets and pillowcase looked very old and worn, and some had holes and stains.

Information relating to people’s health had not been kept updated which could impact on the support they received. One person’s diabetes management plans were not adequately detailed to guide staff in the management of this health condition.

Since the registered manager had left staff had not benefitted from regular supervision or appraisals to discuss their roles and identify areas they needed further support or guidance in.

It was not well documented how complaints had been responded to or what action had been taken when complaints were received.

There was a lack of oversight and leadership at the service. Feedback was obtained with the view of improving the service, but action was not taken or recorded to demonstrate the improvements that had been made.

There were suitable numbers of staff on shift to meet people's needs. Staff demonstrated a good

understanding of how to support people well.

Incidents were recorded and audited to identify patterns. People had their own individual risk assessments according to their needs. Risk assessments had been completed to support people to remain safe.

Staff were trained in safeguarding and understood the processes for reporting abuse or suspected abuse. Appropriate checks were made to keep people safe. Safety checks had been made regularly on equipment and the environment.

People had choice around their food and drinks and staff encouraged them to make their own decisions and choices.

Staff demonstrated caring attitudes towards people and spoke to them in a dignified and respectful way. Staff communicated with people in a person centred and individual way to meet their own specific needs. People were relaxed and happy in their home and at ease around staff.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we have asked the provider to take at the end of this report.

The service has now closed and no one currently lives there. The provider is in the process of de-registering the service with The Commission.