Archived: Pilgrim Homes - Evington Home

Pilgrim Homes – Evington Home is a care home that provides residential and nursing care for up to 30 people. The service specialises in caring for older people including those with physical disabilities, people living with dementia and those who require end of life care. Accommodation is over two floors. Bedrooms are all single rooms with an en-suite facility. At the time of our inspection visit there were 25 people in residency.

At our previous inspection in September 2016 we rated the service as requires improvement. We found the provider had made some improvements to how people’s medicines were managed and administered. Improvements were found to how risks to people’s physical health and wellbeing were managed and care provided was personalised. We also found some improvements had been made to the provider’s governance system used to monitor the quality of the service provided. Further action was needed to ensure those improvements were sustained. In addition the service did not have a registered manager in post. A registered manager is a person who has registered with us to manage the service and has the legal responsibility for meeting the legal requirements in the Health and Social Care Act 2008.

At this inspection we found the service remained requires improvement.

This service is required to have a registered manager. A registered manager was not in post. The provider had appointed two managers. We were aware that they had begun the process to become the registered managers for the service. Following our inspection visit they were confirmed as joint registered managers for Pilgrim Homes – Evington Home.

People told us there were not enough staff to meet their needs and to keep them safe and meant that their health and wellbeing had been put at risk or compromised. For example, people were not supported with their personal hygiene needs to then be able to attend the morning religious service which was important to them. A number of other examples were shared indicated that there was an institutionalised practices and regimes of supporting people. Staff acknowledged that there were delays at time but despite this people’s needs were met. Our observations during the inspection also supported the feedback we received.

The provider’s quality governance and assurance systems was not fully implemented. Audits we looked at were fragmented, lacked attention to detail and no plans to address the shortfalls found. Further action was needed to ensure any shortfalls identified were addressed in order to drive and sustain improvements.

People lived in an environment that was maintained. Further action was needed to ensure the premises and equipment were clean and that staff followed the infection control procedures.

Risks in relation to people’s care and support needs were assessed. People were involved in the development of care plans. That helped to ensure staff knew how people wished to be supported. Care plans were reviewed regularly. However, we found some inconsistencies in the records. The manager told us that the care plans were being transferred to an electronic care planning system. This process would enable care plans to be checked for accuracy and used to review people’s care to ensure any changes to care needs could be met.

People mostly received their medicines safely. People’s dietary and nutritional needs were mostly met. People had access to a range of healthcare services and attended routine health checks.

People’s safety was protected because staff were recruited through safe recruitment practices. We found there were sufficient numbers of staff to provide care and support when people needed it. Staff received an appropriate induction, training, supervision and appraisal.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. The policies and systems in the service supported this practice.

People’s privacy and dignity was respected. Staff’s approach was caring and they knew people well. People were involved in the review of their care plans which helped to ensure they received personalised care that was responsive to their needs. People maintained contact with family and friends. People’s religious needs were met. People’s wellbeing could be promoted through more l opportunities to engage in meaningful activities that were of interest to people.

People’s views about the service had been sought through a survey and at residents meetings. People and their relatives felt confident to raise concerns with the managers. A complaint process was available and advocacy support was made available to people.

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

We previously carried out an unannounced comprehensive inspection of this service on 24 and 25 February 2016. We found that the provider was not meeting the standards we expected and there were breaches of legal requirements. We found people’s care needs and risks were not assessed or reviewed regularly. The care plans were not centred on people’s needs, were not kept up to date and lacked information for staff to support people safely. People were not provided with food and drink that met their dietary and health needs. The management, administration and recording of medicines were not safe. The provider’s quality assurance and governance system was fragmented and ineffective. Audits and quality checks were not always carried out, which meant improvements were not made to the quality of service provided. We issued requirement notices as the provider was in breach of legal requirements. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breaches.

We carried out an unannounced focused inspection of Pilgrim Homes – Evington Home on 29 September 2016. This inspection was carried out to check that the provider had made the required improvements in order to meet legal requirements. At the time of our inspection there were 25 people in residence. We found that some improvements had been made.

We inspected the service against four of the five questions we ask about services. Is the service safe, is the service effective, is the service responsive and is the service well-led. This is because the service was not meeting some legal requirements. This report only covers our findings in relation to those requirements.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for ‘Pilgrim Homes – Evington Home’ on our website at www.cqc.org.uk.

A registered manager was not 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.

The service has been without a registered manager since September 2016 but has not yet cancelled their registration. The registered provider who visited the service at the time of our inspection told us that they were in the process of recruiting a suitably qualified person to manage the service. The care nurse manager who facilitated this inspection was in charge and was supported by the operations manager.

Some improvements had been made in relation to how the provider checked the quality and safety of service provided, however these systems were not yet established. We saw that some actions had been taken as a result of checks however further action was needed to demonstrate improvements made were sustained. People’s views influenced their care and the development of the service. Staff continued to receive the training and support to carry out their roles. This was in order to drive improvement at the service.

We found some improvements had been made that ensured people’s needs were assessed and measures were in place to ensure risks could be managed safely. Care plans were being updated to ensure people’s needs were accurately reflected and there was clear information for staff to follow to ensure people were supported safely.

Improvements had been made so that people’s nutritionals needs were met. Staff sought advice from health care professionals where people’s appetite and weight was of concern. Care plans included the guidance provided by health care professionals for staff to follow to help monitor and ensure people’s nutritional needs were met.

People received their medicines at the right times, as prescribed. We found nurses’ medicines competency was carried out to help assure the provider and people that their prescribed medicines would be given as prescribed. The systems to store, manage and administered medicines were safe and there was guidance for staff to follow to ensure people’s health needs were met. However, further action was needed to demonstrate the improvements made were sustained.

Pilgrim Homes – Evington Home is a care home that provides residential and nursing care for up to 30 people. The home specialises in caring for older people including those with physical disabilities, people living with dementia or those who require end of life care. Accommodation is over two floors accessible using the stairs or the lift. Bedrooms are all single ensuite and a choice of communal lounges and a dining room. At the time of our inspection there were 29 people in residence.

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’s care needs were assessed including risks to their health and safety when they started to use the service. However, these were not comprehensive and care plans lacked detail about the measures to manage risks.

Improvements were also needed with the ongoing monitoring, assessments and reviews of people’s care and treatment. We found staff were aware of people’s needs but did not respond in good time or knew how to respond. People were not always at the centre of the care. Care plans were not always person centred or up to date to ensure staff had clear information as to how to support people to ensure their needs were met safely and reliably.

The systems to store, manage and administer medicines safely were not followed correctly, which could affect people’s health.

The provider’s quality assurance and governance system was fragmented and ineffective. There were limited audits carried out and improvements were limited. The registered manager was aware of the improvement needed to ensure the service was well managed and provided a sustained quality service to people who used the service.

People lived in an environment that was suitably maintained and decorated. There was a secure garden which people could now use safely.

Staff were recruited in accordance with the provider’s recruitment procedures and sufficient staff were available to meet people’s needs. Staff had received the appropriate support, supervision and training and nurses were supported by the provider to maintain their professional competences in the delivery of care and support to meet people’s needs.

People were provided with a choice of meals prepared to suit their dietary needs. Further action was needed to ensure timely advice was sought to prevent people at risk of continued weight loss and poor appetite

The registered manager and staff understood the principles of the Mental Capacity Act 2005 (MCA), and supported people in line with these principles. This included staff seeking consent from people before supporting them. The registered manager sought advice and made appropriate referrals to the local authority when people had been assessed as being deprived of their liberty. Further action was needed to ensure capacity assessments were completed and any decisions made in the person’s best interest were recorded.

People were involved and made decisions about their daily needs and how they wish to spend their day. People had opportunities to take part in activities of interest, continue to observe their faith and attend the daily religious service.

People told us staff were caring and kind and that they had confidence in them to provide the support they needed. The atmosphere at the service was friendly and warm. We saw staff positively engaging with people, and treated them with dignity and respect.

People who used the service and relatives told us if they had any concerns or complaints they would speak with the staff or their relative. People’s views about the service were regularly sought, both individually and at meetings held as part of the quality assurance.

We found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

We spent time in the main lounge and saw that people who used the service got on well and were supportive of each other. Some close friendships had developed between groups of people and we chatted to them as they socialised and enjoyed each others company. One person said, 'We all get on like a house on fire ' I have made so many friends here.'

People told us the staff were warm and caring. One person said, 'The staff are friendly and look after me so well. They are very good at what they do.' Another commented, 'The staff are lovely and they all kiss me. They come and chat to me when I'm sitting in the lounge and will help me with anything I want.'

When we visited the home was about to undergo major refurbishment. The manager said that when the work was completed all bedrooms would be single with ensuite facilities, and there will be a large secure garden at the front of the home. People told us they were looking forward to the work being carried out. One person said, 'I'm really pleased my room's being done. It's going to be lovely, particularly as I'm having my own ensuite'