Pilgrims View

Updated 12 December 2017

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This was a comprehensive inspection, which took place on 21 November 2017 and was unannounced.

The inspection was carried out by one inspector and an expert by experience. An expert by experience is a person who has personal experience of using similar services or caring for older family members.

Before the inspection, we asked the provider to complete a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. We looked at previous inspection reports and notifications about important events that had taken place in the service, which the provider is required to tell us by law. We used all this information to plan our inspection.

People’s ability to verbally communicate was limited, so we were unable to talk with everyone. We observed staff interactions with people and observed care and support in communal areas. We spoke with one person with limited communication skills.

We spoke with seven care staff, one team leader, one activities coordinator, cook and the assistant manager. We spoke with five groups of visiting relatives. We also requested information via email from healthcare professionals involved in the home. These included professionals from the community mental health team, local authority care managers, continuing healthcare professionals, NHS and the GP.

We looked at the provider’s records. These included four people’s care records, which included care plans, health records, risk assessments and daily care records. We looked at six staff files, a sample of audits, satisfaction surveys, staff rotas, and policies and procedures.

We asked the registered manager to send additional information after the inspection visit, including training records, some audits, business continuity plan and minute of managers meeting. The information we requested was sent to us in a timely manner.

Updated 12 December 2017

The inspection was carried out on 21 November 2017, and was an unannounced inspection.

The service provides care and support for up to 44 older people who do not have nursing needs, but some of whom are living with mild to moderate dementia. At the time of our inspection there were 36 people using the service. Two of these people were cared for in bed. The accommodation was situated over four units; each had its own dining room and lounge areas and small kitchenette.

At the last Care Quality Commission (CQC) inspection on 30 September 2015, the service was rated Good in Safe, Effective, Caring and Well Led domains with an overall Good rating. However, the Responsive domain Required Improvement. We recommended to the provider to seek advice and guidance from a reputable source and to carry out research on published guidance about the benefits of and types of activities recommended for people living with dementia.

At this inspection we found the service remained good.

The service has a registered manager. The registered manager was not available on the day of our inspection as they were on holiday. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The registered manager provided good leadership. They checked staff were focussed on people experiencing good quality care and support.

There were activities located around the home for people to engage with independently and each dining room table was set up for people to be engaged in different activity. All staff took the time to sit and engage with people and take an interest in what people were doing. Staff made time for people.

Staff encouraged people to actively participate in activities, pursue their interests and to maintain relationships with people that mattered to them.

People and staff were encouraged to provide feedback about how the home could be improved. This was used to make changes and improvements that people wanted. Records were consistent and robust.

People continued to be safe at Pilgrims View. Staff knew what their responsibilities were in relation to keeping people safe from the risk of abuse. Staff recognised the signs of abuse and what to look out for. There were systems in place to support staff and people to stay safe.

Medicines were managed safely and people received them as prescribed.

There were enough staff to keep people safe. The registered manager continued to have appropriate arrangements in place to check the suitability and fitness of new staff.

Each person had an up to date, personalised support plan, which set out how their care and support needs should be met by staff. These were reviewed regularly.

Staff received regular training and supervision to help them to meet people's needs effectively.

People were supported to eat and drink enough to meet their needs. They also received the support they needed to stay healthy and to access healthcare services.

The Care Quality Commission is required by law to monitor the operation of the Deprivation of Liberty Safeguards. The provider and staff understood their responsibilities under the Mental Capacity Act 2005.

Staff showed they were caring and they treated people with dignity and respect and ensured people's privacy was maintained particularly when being supported with their personal care needs.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. The policies and systems in the home supported this practice.

The registered manager ensured the complaints procedure was made available in an accessible format if people wished to make a complaint. Regular checks and reviews of the home continued to be made to ensure people experienced good quality safe care and support.