Pelham Manor

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The provider was previously in breach the legal regulation in relation to safe care and treatment. Although the provider had made improvements in how they monitored infection control, they remained in breach due to the ineffective systems used to assess risk and manage medicines. The provider was previously in breach of the legal regulation in relation to staffing. Improvements in processes for staff recruitment were found at this assessment and the provider was no longer in breach of this regulation.

This service scored 53 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff knew how to report any accident, incidents or safety concerns. These were reviewed by the manager to identify if there were any patterns or trends. Some people had anxieties and any incidents relating to these were shared with the positive behaviour support team (PBS). This was so they could help identify any triggers and assess the effectiveness of strategies to support people. PBS isa person-centred approach that aims to improve the quality of life for people who find it difficult to communicate their distress and anxiety.

The provider had carried out an analysis of a recent event when a person had not received their allocated staff support hours. This was to determine the root cause of why the person had not been supported with the level of staff support they required and actions that needed to be put in place to prevent this happening again. These lessons learned had been shared with the staff team who were addressing them at the time of our assessment.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. However, they had not always ensured continuity of care when people had moved between different services.

When a person had moved between services, the provider had not always ensured agreed staffing levels were in place. The provider had acknowledged this shortfall and was taking actions to minimise the risk of this happening again. The provider had also not ensured that all relevant information in relation one person’s care and treatment had been received when they had moved to the service. The manager was accessing these records at the time of our assessment.

A relative told us that before people moved to the service they undertook, “A number of extended visits for them to get the idea of what it would be like to move there.” This included meeting staff and the other people who lived at the service to see if it was the right place for them.

Hospital passports were in place to support people when they needed to go to hospital or attend clinic appointments. These records were being updated to ensure they contained all the necessary information for external professionals to know about the person’s health. Staff told us hospital passports had been given to health care staff when people had attended hospital.

The service had established relationships with a range of health care professionals including speech and language therapists, psychologists and community nurses. Referrals had been made to health professionals in a timely manner and professional guidance was followed.

The provider worked with people and partners to understand what being safe meant to them and the best way to achieve that. Staff understood how to ensure people lived in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

Staff had received training and had their competency assessed in how to recognise and report abuse. They knew to report any concerns to senior or management staff and how to whistle blow. This is where staff are protected if they raise concerns internally. Staff also knew how to report to external agencies should they not be listened to. The manager understood how to report safeguarding concerns to the local authority who is the lead agency for safeguarding. A relative told us, “There was a safeguarding a year ago and it got investigated and sorted.”

We observed staff interacting and supporting people to maintain their safety. Staff provided people with assistance who required it, to move around their home. Relatives told us their family members were safe living at the service. Comments included, “He is safe. Staff make sure nobody hurts themselves” and “She is always happy to go back to Pelham when she has been with us. She is happy there, so we would know if something is wrong."

The provider did not work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risks relating to the management of constipation were not well managed. NHS England has highlighted that people with a learning disability are at significantly higher risk of constipation than the general population. Some people were prescribed medicines to take if they showed signs of constipation such as not having regular bowel movements or if their stools were other than soft. Staff told us they used to make a record to people’s bowel movements to monitor people for constipation. However, they had ceased this practice as they had been told it was ‘institutional’. This was contrary to the providers medicines policy which stated that staff should refer to a person’s bowel chart. As a result, staff were relying on verbal communication amongst themselves rather than accurate records to ensure medicines were given as prescribed to minimise the risk of people being constipated. One person was prescribed medicines to relieve constipation did not have an associated risk assessment in place. Staff were guided that the person maybe in pain due to constipation but not what action they should take if they had constipation.

The manager took action during our assessment to reintroduce bowel charts for people at risk of constipation. Staff demonstrated to us how they would record this information going forward. We will check if this practice has been embedded at our next assessment.

People’s care and support records contained a range of risk assessments relating to their health and social care. These included enabling people to pursue their interests, eat their meals safely and be a part of their community through positive risk taking. There was clear guidance about how to support people who had seizures to go out and take part in activities they enjoyed. Staff were knowledgeable about this guidance and how to put it into practice to keep people safe. A relative told us, “Staff are always there when he baths due to epilepsy, so he is safe.”

Risks to people in the environment were assessed, such as slips, trips and falls. However, one person’s environmental risk assessment had taken place at their previous home. This had not been reviewed or updated to ensure risks for this person were minimised at Pelham Manor.

Each person had a personalised evacuation plan with guidance for staff and emergency services on the support they would need to evacuate the building safely in the event of a fire. However, staff were not aware of the individual guidance for a person. The last fire assessment in March 2025 recommended a fire drill to be carried out at night time, when only 2 staff were on the premises. Although an additional fire drill had taken place, it was recorded that 3 staff were present. Therefore, the provider could not be assured staff were competent in safely evacuating people from the service at night time in a timely manner. There was a portable kit of essential items for staff to grab by the front door in the event of a fire.

Some people had risk strategies around their anxieties and emotions which had been developed by the positive behaviour support team (PBS). These set out how to recognise the early warning signs that a person was becoming upset, and the actions staff should take to reassure them. PBS staff reviewed incidents in relation to each person and adjusted the person’s plan as necessary. A member of the PBS team was reviewing a person’s plan on 1 of the days of our assessment.

The provider did not always have effective systems to detect and control potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Although we did not identify any significant hazards there were no systems to regularly check the environment to make sure it was safe and free from potential risks. Apart from a request to replace a person’s flooring with a more suitable alternative, there was no record on the providers’ maintenance portal. We identified several areas that would require addressing soon to prevent them becoming a potential risk. This included the dining room flooring becoming worn in specific places and a bath front becoming unattached.

Regular servicing of equipment had taken place such as the maintenance of gas, water and electricity supplies. Regular checks and maintenance were carried out of fire fire-fighting equipment and with regards to legionella.

Staff had regular supervision but it could not be assured they had all the training they required to support the people in their care.

The provider could not be assured staff had the necessary skills to provide safe care that met people’s needs. There were enough staff deployed who received effective support and supervision.

Staff told us they had undertaken the training they needed for their role and to support people’s individual needs. They said this included the wide range of strengths and impairments that people with a learning disability and autistic people may have. Staff said that in addition they had undertaken training in people’s specialist support needs such what to do if a person had a seizure or difficulty swallowing their food. However, the service’s staff training matrix identified shortfalls in several areas including deprivation of liberty safeguards, safeguarding and epilepsy. The manager explained training was provided by four different training providers and this information had not been effectively merged to form 1 report. They had checked individual staff training certificates to ensure staff were trained in supporting people with specialist medication for seizures. We viewed staff competency checks in safeguarding. This indicated the staff training matrix was not up to date, but the provider did not send an updated version during our assessment to give us this reassurance. Relatives told us that staff had the necessary skills to support people. Comments included, “Staff know what to do if he has a seizure. You can always be sure there are two staff on shift who know what to do as they have seen a seizure as well as having a session about it” and “Staff are very caring and good at calming her down and her understanding things are not as bad as she thinks they are.”

New staff completed an induction, including shadowing experienced staff and completing essential training. The induction process included completing the care certificate before working on their own. However, the staff training matrix did not show all staff’s completion of the care certificate. The care certificate are the standards employees working in adult social care need to meet before they can safely work unsupervised.

The staffing levels required for each person were assessed before they moved to the service in partnership with the funding authority. Some people had shared staffing hours, and some people also had additional one to one hours to meet their needs. The provider had recognised that some people’s needs had changed since they moved to the service. However, they had yet to formally reassess people’s dependency needs to ensure there were sufficient staff available to meet their changed needs. The staff team were a mixture of staff who had worked at the service for a number of years and some newer staff. A relative told us, “It is a good staff team and I don’t want it to change.”

The provider had undertaken all necessary checks for new staff to ensure safe recruitment decisions. This included obtaining work references, explanations for any gaps in people’s employment history and Disclosure and Barring checks (DBS). DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

The provider assessed and managed the risk of infection.

The provider had systems and processes in place to assess and manage the risk of infection. Staff had received infection prevention and control training and understood what to do to mitigate infection risks. Staff supported people to clean their rooms and we saw all areas of the service were clean on the day of our assessment.

We saw supplies of personal protective equipment (PPE) such as gloves and aprons situated around the service, to provide safe care. We observed staff using PPE appropriately. Relatives said the service was clean when they visited.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

There were significant shortfalls in the management of people’s medicines resulting in people being at risk of not receiving their prescribed medicines. People had been assessed as not able to manage their own medicines and therefore were reliant on staff to do this for them safely. Staff were not consistently following the provider’s medicines policy to ensure the safe management of medicines. This policy stated that staff should record on the medicines administration record (MAR), the quantity of medicines received from the pharmacy and the amount carried forward in each 28 day cycle. However, staff were not recording the number of medicines carried forward, nor were they accurately recording the number of medicines received from the pharmacy. For example, when the pharmacy had not delivered a complete 28 day supply of a medicine, staff had recorded, ‘to follow’ and not how many medicines had been received. These errors had resulted in there being discrepancies between the amount of medicines in stock and the amount recorded on the MAR sheet for all 3 people’s medicines we checked. We found some people only had 2 or 3 days of their prescribed medicines in stock, including tablets to treat a person’s high blood pressure.

The service took immediate action by carrying out a full reconciliation of each person’s medicines and ordering medicines when people were in short supply. A full investigation was carried out and an action plan developed. This included ensuring staff understood their responsibilities with regards to completing accurate MAR sheets and commencing weekly stock checks.

Protocols for people who had medicines prescribed to be taken when needed (PRN) were not always provided in sufficient detail. The providers medicines policy for bowel management stated that staff should refer to the bowel chart and record in the PRN protocol how long to wait before contacting the GP if a stool is not passed. However, this information was not included in people’s PRN guidance for bowel management. When staff had administered PRN medicines to people, they had not recorded the reason why the medicine had been given, to ensure it was in line with the PRN protocol.

Some people regularly stayed with a relative and needed to take their medicines on these visits. The providers medicine policy stated that a record should be made of all medicines going out and returned when handling medicines away from people’s usual care setting. These records were not always accurately completed. When a person went on social leave on 6 November 2025 it had been recorded that they left with 63 or 64 tablets of a specific medicine. When another person left the service on 17 October 2025, the number of medicines on their return was not recorded. We observed that people who needed PRN medicines for seizures, took these with them in a dedicated bag which contained full guidance about how and when they should be administered.