Pelham Manor

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

The provider was previously in breach of the legal regulation in relation to consent to care. Sufficient improvements were found at this assessment and the provider was no longer in breach of this regulation.

This service scored 63 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always make sure people’s care and treatment were effective because information about their health, care, wellbeing and communication needs was not easily available to staff.

People’s health, social and emotional needs were assessed before they moved to the service. These assessments were used to develop each person’s care plan. Peoples’ care plans were being transferred from paper to digital records. Although staff were knowledgeable about people’s health and communication needs some of this information was either missing or care records referred to specific care plans that had been archived rather than uploaded to people’s care records. For example, staff described the support a person received from the community nurse with a dressing. This information was contained in their medical care notes. Staff told us the dressing needed to remain dry and not get wet due to infection risks. However, this essential information was missing from the information about the support they needed with their personal care.

As a result, care plans did not always give staff a comprehensive plan of how to support people’s needs. On the second day of the assessment the manager had an action plan in place. This detailed how each person’s paper care records would be checked and moved over to the digital system, within a 3 month timescale.

The provider planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

People’s needs around their eating and drinking had been assessed and guidance sought from health care professionals where people were at risk of choking. Where people were prescribed a modified diet this information was recorded using the International Dysphagia Diet Standardisation Initiative (IDDSI). This guidance was located in the kitchen so it was available for staff supporting people to prepare their meals. IDDSI isa global framework providing a common language for texture-modified foods and thickened liquids for people with swallowing difficulties

We observed people being offered drinks and supported to make drinks throughout the day. People had access to the kitchen and were supported by staff with aspects of their meal preparation.

The provider used positive behaviour support (PBS) which is a recognised proactive support framework for people who find it difficult to communicate their anxieties. Staff had received training in supporting people to manage their anxieties and promote a positive and safe environment for everyone involved.

The provider worked well across teams and services to support people.

The service worked with a wide range of health and care professionals including community nurses and speech and language therapists. The clinical lead paramedic at the GP practice communicated with the service weekly to discuss people’s health needs.

Where guidance had been provided by professionals, we saw it had been recorded in people’s care notes and that it was followed by care staff. Relatives told us staff supported people to attend medical appointments.

The provider supported people to manage their health and wellbeing. Staff supported people to live healthier lives.

Information was available about people’s medical conditions and records showed people were supported by staff or their relatives to attend related health care appointments. Relatives were positive about the support staff provided to manage people’s health. Comments included, “They see the doctor and dentist” and “She had an operation to do with her teeth last week and we were fully involved.”

Staff monitored people’s health by keeping people’s weights under review to assess if there were any significant increases or decreases. Some people were supported daily with short walks in order to exercise. Some people had been supported, as recommended by a health professional, to change to decaffeinated coffee as caffeine can increase the regularity of some people’s seizures.

The provider did not always routinely monitor people’s care and treatment to continuously improve it.

There were inconsistencies in how people were engaged to ensure their life ahead was a life they choose. The service used a keyworker system. A keyworker is a named member of staff who has responsibility for working with certain people, taking responsibility for planning that person’s care and liaising with family members. The service had identified that some people were not having regular meetings with their keyworkers and had reminded staff of their responsibilities. There were positive outcomes for people who did have regular meetings. They had opportunities to discuss what made them happy, were given emotional support and talked about how they were working towards their goals. We observed a person being supported according to 1 of their goals during our assessment. Relatives told us there had been a number of changes to people’s keyworkers. Comments included, “There is a keyworker, they have changed and I can’t remember their name” and “He has a keyworker and she is very kind.”

An additional way of monitoring people’s outcomes was to hold review meetings with people, and those who were important to them, such as family members and a representative from the placement funding authority. Most relatives told us there were not regular review meetings. A relative told us, “There used to be regular review meetings but not anymore. We would have a recap of what was going on, and this was useful.” Another relative said, “We had a review meeting a few weeks ago, but I could not attend.”

Staff understood the importance of gaining people’s consent and respected this when delivering person-centred care and treatment, but mental capacity assessments did not always reflect this.

Although improvements had been made in assessing people’s capacity to make specific decisions, this good practice was not consistent across the service. The provider had highlighted these inconsistencies in an audit of the service in September 2025. They found that although best interest meetings had included a range of people, including family members, the assessments of people’s capacity had not all been completed accurately. We found some assessments clearly evidenced people had been helped to understand information by giving it to them in different ways and formats. Checks had been carried out if they could retain and weigh up the information to communicate their decision. But in other assessments it was not always clearly recorded how people had been assisted to understand the information in order to assist them to make specific decisions.

Staff understood the principles of the Mental Capacity Act 2005 (MCA) to respect people’s choice to make decisions whilst giving them relevant information and encouragement so they could make a fully informed decision. We observed staff gaining people’s consent before offering any support or assistance.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the MCA. We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that DoLS applications had been submitted to the appropriate authorising bodies where required. There were systems to monitor DoLS to ensure people were only deprived of their liberty to receive care and treatment when it was in their best interests and legally authorised under the MCA. The provider was aware of and complied with any conditions attached to authorisations.