Pollard House provides accommodation and personal care for up to 28 elderly people accommodated three floors. On the day of the inspection there were 23 people living at the home. The manager told us 11 people who lived at the home had a diagnosis of a dementia. The service had a registered manager in place. ‘A registered manager is a person who has registered with the Care Quality Commission to manage the service and shares the legal responsibility for meeting the requirements of the law with the provider.’
People told us they felt safe in the home and nobody raised any concerns with regards to their safety. We found procedures were in place to ensure people were protected from abuse and staff understood how to apply these procedures to keep people safe from abuse.
We found the location to be meeting the requirements of the Deprivation of Liberty Safeguards. People’s human rights were therefore properly recognised, respected and promoted. CQC monitored the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes and hospitals. We did not observe any restrictions of people’s liberty. The manager had a good understanding of DoLS and was able to give us examples of where they had sought advice from the local authority DoLS team to ensure people’s freedom was not restricted.
Staff we spoke with had a good understanding of the Mental Capacity Act (MCA) and how to ensure the rights of people with limited mental capacity to make decisions were respected.
The medicine management system required improvement. Robust documentation was not in place which meant it could not be evidenced that people’s medication had always been given. Some people had not received their medication on time which meant they may have experienced unnecessary pain. These problems we found breached Regulation 13 (Management of medicines); of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.
Two healthcare professionals who regularly visited the service told us they thought the service was effective in meeting people’s needs. We found people’s choices and preferences had been sought in the way they wanted their care to be delivered and staff were familiar with people’s needs. Care plans contained information on people’s assessed needs, preferences and choices; although some sections required more detail adding to ensure staff had the necessary information to ensure they delivered effective care.
People were given choices with regards to their daily lives, although the mealtime experience required improvement. People said there was not enough choice of foods and we observed one person’s comments regarding the food were not listened to.
The service worked effectively with healthcare professionals and was pro-active in referring people for treatment and diagnosis. Staff were good at following advice given by health professionals to ensure effective care.
People and their relatives all remarked that the service and its staff were caring and said staff were kind and compassionate. This was confirmed by the caring interactions and positive relationships between staff and people who used the service which we observed on the day of the inspection.
People were able to express their views and opinions in regards to their care through various mechanisms including a confidential comments and suggestions box, regularly resident meetings and resident/relative care plan reviews. We saw evidence people’s views had been recorded and action taken in response.
Regular reviews of people’s care took place and changes were made when people’s needs changed. Staff were aware of people’s ongoing care needs to enable them to deliver responsive and appropriate care.
People who used the service and staff all praised the manager and said they would listen to their concerns. We found an open and honest culture within the organisation with the manager committed to further improvement of the service.
We found risks to people’s health, safety and welfare were identified in three of the five people’s care plans we looked at. However, two people’s care plans were missing risk assessment documentation which meant the service had not assessed the measures needed to keep these people safe.
An incident management system was in place and there was analysis and clear lessons learnt in place for safeguarding incidents. However, accidents such as falls were not analysed for trends although this was something the manager showed us they were in the process of implementing. There was no documentation in place showing the learning from accidents to reduce the likelihood of future harm.
Improvements were required to the provider’s audit systems as the problems we identified with medication were not identified through the medication audit system. Deficiencies in risk assessment documentation were also not identified by the providers internal audit systems.
The above problems we found breached Regulation 10 (Assessing and monitoring the quality of service provision); of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of the report