Pelham Grove Care Home

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 people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to 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 people could be harmed.

The service was in breach of legal regulation in relation to learning culture and safeguarding.

This service scored 47 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice. For example, the systems in place to keep people safe and prevent avoidable harm were not effective. Managers and staff were not consistently recording incidents when required to do so. The provider and staff described several incidents involving people; however, when we requested the associated incident reports, these were not provided.

There was no evidence of analysis of incidents to identify themes or trends to help prevent further occurrences. Records reviewed for the previous 12‑month period showed there had been no robust investigation or evaluation of incidents, no clear identification of lessons learned, and no documented actions taken to reduce the likelihood of similar incidents happening again.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services. For example, there were no structured or written handovers, which meant there was no reliable way to make sure all staff received accurate and up‑to‑date information about people’s care needs or any risks. Staff told us they mainly relied on verbal updates or informal conversations to understand any changes in people’s needs.

We discussed this with the registered manager, who took the appropriate action to reduce the risk. A written handover system was introduced straight away, ensuring key information was recorded, easy to access and shared consistently with all staff.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how this could be achieved. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately. For example, records of safeguarding incidents were not maintained, and the registered manager was unable to demonstrate a clear understanding of which incidents required escalation. Safeguarding measures implemented following incidents were not consistently followed, meaning protective actions were not always agreed or put into practice to reduce the risk of further harm.

Opportunities to identify potential neglect or abuse, and to prevent the risk of reoccurrence, were missed. For example, body maps we reviewed showed multiple instances where people had sustained unexplained bruising and skin tears. These concerns had not been reported to the local authority safeguarding team for further investigation, as required under statutory safeguarding procedures.

The provider had a safeguarding policy in place, and staff had completed safeguarding training. However, our findings highlighted significant gaps in both management and staff knowledge and understanding of the systems and processes for safeguarding people from the risk of abuse.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs in a safe and supportive way enabling people to do the things that mattered to them. For example, people were not involved in managing risks that may affect their safety. Risk assessments had not always been completed or kept up to date to provide staff with the guidance needed to safely support people with specific risks. This included people living with diabetes, where there was no clear guidance for monitoring and responding to risk.

The provider did not always detect and control potential risks in the care environment. For example, rooms containing hazardous items, substances and equipment were not secured, which meant people could easily access them. In addition, radiator covers along corridors and within communal lounge areas were not securely bolted to the walls, leaving hot radiators exposed and increasing the risk of burns or injuries. The issues were raised on site with the registered manager who took immediate action.

Records showed the required safety checks had been carried out on equipment and utilities, demonstrating they were in safe working order.

The provider did not always make sure staff were supervised to carry out their job safely. For example, rotas did not consistently reflect safe staffing levels, particularly during the night. This meant people were at risk of not receiving the care and support they needed. We reviewed records relating to staff supervision and oversight. We were not assured all staff were receiving the appropriate level of supervision to ensure peoples safety. This placed people at risk because the provider could not be confident staff were working safely and in line with individual supervision requirements. Following the site visit the provider assured us they were actively addressing this concern.

However, recruitment processes were safe, and staff received appropriate training for their role.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. For example, overall, the home was clean, well maintained and smelt pleasant throughout. All staff had received current IPC training and could access relevant good practice guidance when needed. PPE stock levels were well maintained, and staff used and disposed of it safely in line with procedures.

The provider did not always ensure medicines and treatments were managed safely or in a way to meet people’s needs, capacities and preferences. For example, time‑specific medications did not have administration times recorded, which increased the risk of doses being given too early or too late. Handwritten instructions entered on to medication records were not consistently countersigned to ensure the accuracy of the information recorded. In addition, ‘when required’ medicines protocols lacked essential detail to guide staff on when these medicines should be offered, the symptoms they were intended to treat or alternative strategies to consider before the medicine was administered. The registered manager provided assurances showing this concern had been addressed.

However, staff responsible for medicines management had completed the necessary training and competency assessments to support safe practice. Medicines were stored securely, and daily temperature checks were completed to ensure storage conditions remained within safe limits. People told us they received their medicines on time and in the way they preferred.