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We are carrying out a review of quality at Pelham House. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary


Overall summary & rating

Inadequate

Updated 12 October 2021

About the service

Pelham House is a residential care home providing personal care to 22 people at the time of the inspection. The service can support up to 22 people.

People’s experience of using this service and what we found

People were not protected from the risks of avoidable harm. Risk assessments were not robust and did not give staff the required guidance to support people safely. People did not always receive their medicines as prescribed.

There were not enough staff to meet people’s needs. An overview of personal emergency evacuation plans had not been updated for five months, despite the service now having a further eight people living at the service since it was last completed. Staff told us there were not enough staff on duty at night and that people’s call bells were sometimes ignored.

There continued to be a lack of oversight and scrutiny. The new manager had not received a handover from the previous manager and the auditing systems was ineffective and not robust.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection (and update)

The last rating for this service was Inadequate (published 9 September 2021).

At this inspection enough improvement had not been made and the provider was still in breach of regulations.

Why we inspected

The inspection was prompted in part due to concerns received about the management of risks to people’s health, safety and welfare, staffing and management oversight of the service. A decision was made for us to inspect and examine those risks.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Pelham House on our website at www.cqc.org.uk.

You can see what action we have asked the provider to take at the end of this full report.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection.

We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so. We have identified continued breaches in relation to unsafe medicines management, poor assessing and mitigating of risk, inadequate staffing levels, and a lack of leadership and oversight.

Full information about CQC's regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Special Measures

The overall rating for this service is 'Inadequate' and the service is therefore in 'special measures'. This means we will keep the service under review and, if we do not propose to cancel the provider's registration, we will re-inspect within 6 months to check for significant improvements. If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying t

Inspection areas

Safe

Inadequate

Updated 12 October 2021

At our last inspection we rated this key question Inadequate. We have not reviewed the rating at this inspection. This is because we only looked at the parts of this key question we had specific concerns about.

Effective

Good

Updated 12 October 2021

Caring

Requires improvement

Updated 12 October 2021

Responsive

Good

Updated 12 October 2021

Well-led

Inadequate

Updated 12 October 2021

At our last inspection we rated this key question Inadequate. We have not reviewed the rating at this inspection. This is because we only looked at the parts of this key question we had specific concerns about.