- Care home
Pelham Manor
Assessment report published 24 February 2026
Contents
Ratings
Our view of the service
We carried out this assessment between 8 December to 19 December 2025. Pelham Manor is a residential service providing support for up to 7 adults with a learning disability and/or autism. At the time of our assessment there were 6 people using the service.
We undertook this assessment due to concerns we received about people’s care and treatment. We found concerns about lack of details in people’s care records were partially substantiated. We assessed the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence and good access to local communities that most people take for granted.The provider was previously in breach of 4 legal regulations, in relation to safe care and treatment (infection control), following the principles of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (consent), the recruitment of staff and governance. Although the provider had improved the monitoring of infection control, they were now in breach of the regulation with regards to assessing risks and the management of medicines. Sufficient improvements were found in consent and staff recruitment at this assessment, and the provider was no longer in breach of these regulations. However, improvements were not found in the governance of the service and the provider remains in breach of this regulation.
Assessments of potentials risks to people during their care and in their environment were not comprehensive enough to ensure people’s safety. Although people told us they knew what to do in the event of a fire, a practice drill had not taken place with minimal staffing levels to ensure people could be evacuated in a timely manner. Risks associated with managing constipation had not been minimised.
There were significant shortfalls in the management of medicines resulting in the provider not being able to evidence if people had taken their medicine as prescribed by their doctor. Based on our feedback the manager carried out a complete count of all medicines in stock and reconciled these with each person’s medicine records.
The provider did not always ensure that clear and accessible records were kept of people’s care needs or staff training. Care records essential to people’s care were not easy to access as they were either kept in paper format, on the electronic care system or had been archived. Some key pieces of guidance for people’s support needs were not available. The manager set out an action plan to address this shortfall over the next three months. Staff training records were not accurate so it could not be assured staff had all the training they needed for their roles.
Staff knew people well and were able to describe their communication, personal and health needs. People were supported to ensure they had food which met their preferences and were involved in its preparation. Staff worked with a range of partners involved in people’s care and monitored people’s health needs.
People were treated with kindness and compassion. Staff understood the importance of protecting people’s dignity and treated people as individuals. People had choice in their care and were encouraged to take part in a range of activities and maintain relationships with family and friends.
The manager was new to the service and had not been registered with the CQC. They were open and honest during the assessment process and acknowledged areas where the service needed to improve.
People's experience of this service
Most people living at the service were not able to tell us verbally about their experiences. During the assessment visit we spoke with people and observed staff interacting and supporting them with their daily routine. We spent time in the lounge observing people preparing to go out for the day and interacting with staff. One person showed us their bedroom and around their home. We spoke with staff about their roles and understanding of people’s care needs. We telephoned peoples’ relatives to gain their feedback of peoples’ care and treatment.
People said they felt safe as they knew what to do if there was a fire in their home. Relatives said their family member was safe as staff knew them well. They described how staff knew people’s likes, dislikes and ‘quirks’. They said this was important as if their family member became ill or was not acting like their normal self, staff were able to pick up on this and seek guidance and support.
Relatives said staff supported people to attend medical appointments and maintain their health. There were mixed views about how effective the service was at communicating changes in people’s needs. Relatives felt confident to make a complaint if they needed.
Relatives said people went out regularly and led busy lives. This enabled them to take part in a range of activities, and special events were celebrated such as birthdays and meet ups with other people who used the providers services.
We observed staff communicating according to people’s individual needs. Relatives said people were given choices in their day to day lives. They said they could visit whenever they wanted and were made to feel welcome. Relatives described how staff supported people to be independent in a kind and gentle way. A relative told us, “I feel it is second to none. I think the staff are all friendly and have made it like one big family with the residents."