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Archived: Pitchill House Nursing Home

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All reports

Inspection report

Date of Inspection: 15 August 2011
Date of Publication: 19 October 2011
Inspection Report published 19 October 2011 PDF

The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care (outcome 16)

Not met this standard

We checked that people who use this service

  • Benefit from safe quality care, treatment and support, due to effective decision making and the management of risks to their health, welfare and safety.

How this check was done

Our judgement

The provider has not developed action plans to adress the shortfalls identified during their quality assessment process.

User experience

People did not feel they had a say in the way the home was run, but they told us they had some control over their care and how they spent their day. One person told us, ‘I get up when I like and go to bed when I like. The staff give me the care I want.’

A relative told us it had been difficult to ‘pinpoint’ who was in charge if they wanted to raise a concern so they were not confident their concerns would be acted upon.

Other evidence

Southern Cross undertakes internal service quality inspections.

We looked at the outcome of the April 2011 internal key outcome inspection. It was a very comprehensive audit of all aspects of the service. It evidenced a general deterioration across all quality themes and found poor outcomes in care and support, environment, staffing and management and leadership.

There was no evidence that action plans were developed to implement improvements.

We looked for evidence of clinical supervision. We saw records to demonstrate that all nurses had supervision sessions in body mapping, medicine administration record (MAR) documentation and medication counting and handover. This was in response to several recent medication errors.

There was limited evidence that staff received regular supervision or appraisal.