Pelham House Residential Care Home with Dementia

Updated 19 July 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was undertaken by three inspectors.

Service and service type

Pelham House Residential Care Home with Dementia is a 'care home'. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Pelham House Residential Care Home with Dementia is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of the inspection there was a registered manager in post. However, they were not present at the inspection.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We reviewed information of concern we had received about the service. We used all this information to plan our inspection.

During the inspection

We undertook observations around the service and at different times. For example, we observed people’s interactions with staff during activities and during meal times. We spoke with three people and five relatives about their experience of the service. We spoke with the admin manager, the provider, two care staff, and the cook. We also spoke with two visiting healthcare professionals. We reviewed a range of records including four care plans, medication records and two staff files. We looked at various records relating to the management of the service, including policies and procedures.

Updated 19 July 2023

Pelham House Residential Care Home with Dementia is a residential care home providing accommodation and personal care to up to 30 people in one adapted building. The service provides support to people with a range of health care needs, such as dementia and diabetes. At the time of our inspection 27 people were using the service

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

Medicines were not always administered or stored safely. The clinical room and enclosed cupboards where medicines were stored were left unlocked and unattended. This meant there was a risk of people consuming medicines that they were not prescribed. There were some risk assessments in place, however risks were not always properly assessed or didn’t contain enough information to enable staff to support people appropriately.

Risks to people were not always managed effectively, including people’s health needs. These included that people lived with diabetes and used a catheter.

Staff had not always recognised potential safeguarding incidents and lack of management oversight meant these had not been reported to the local authority in line with the providers policy. Some people told us they felt safe. One person said, "I do feel safe. There are enough people that make sure I am. If I needed anything I, would ask”.

There were sufficient staff deployed, however, the provider did not knew what staff were being sent from the agency or what skills and experience they had. This meant that there was a risk of staff being deployed to areas of the service without having the necessary skills to support people appropriately.

There was a lack of oversight of the quality and safety of the service by the provider. There were not adequate systems and processes in place to monitor the quality of care or sufficiently robust to identify any shortfalls or concerns. .

People told us positive things about the care they received from staff. One person said, "I think the staff are caring and look after me well. They are all very kind and patient".

People gave feedback about the service using surveys and questionnaires, but people said they hadn’t completed them for a while.

People told us that they used their call bells if they needed assistance and these were responded to in a timely fashion.

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 requires improvement (published 6 December 2022). The service remains rated requires improvement. This service has been rated requires improvement for the last four consecutive inspections.

Why we inspected

We received concerns in relation to the care people received. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

The inspection was also prompted in part by notification of an incident following which a person using the service died. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of the incident. However, the information shared with CQC about the incident indicated potential concerns about the management of risk of specific health needs. This inspection also examined those risks.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Pelham House Residential Care Home with Dementia on our website at www.cqc.org.uk.

The overall rating for the service is requires improvement based on the findings of this inspection.

Since the inspection, the local authority has carried out a number of quality assurance visits and to date, report that the provider has engaged with them in addressing the shortfalls that are set out in this report.

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

Enforcement

We have identified breaches in relation to safe care and treatment, safeguarding and good governance.

Please see the action we have told the provider to take at the end of this report.