CQC report explained · a residential care home
What the CQC found at Pelham Grove Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, September 2020
Inspected but not rated; inspectors found good infection control arrangements during the August 2020 visit.
This was a targeted inspection on 18 August 2020. Inspectors looked at infection prevention and control during the coronavirus pandemic. The visit was announced.
Inspectors found a managed visiting policy, with symptom checks, appointments, social distancing and protective equipment. They also saw guidance, hand sanitiser and protective equipment around the home.
Staff and residents had received regular coronavirus testing, and the home had registered for whole-home testing. Inspectors saw staff using the required protective equipment and were assured that infection control arrangements were safe.
The home was inspected but not rated. This report does not give an overall quality rating or ratings for the other areas of care.
Managed visiting
Visitors were screened, visits were by appointment, and social distancing and protective equipment were part of the arrangements.
“The home had a clear visiting policy in place to ensure visiting was carefully managed.” from the report
Protective equipment
Inspectors saw staff wearing the required protective equipment while supporting people.
“We observed staff wearing the required PPE whilst supporting people at the home.” from the report
Testing arrangements
Staff and residents had received regular coronavirus testing, and the home had registered for whole-home testing after a local pilot ended.
“Staff and residents had received regular Covid testing through a pilot scheme in the local area.” from the report
Inspectors raised no specific concerns in this report.
- 01How are visitor symptom checks, appointments, social distancing and protective equipment managed now?
- 02Is whole-home testing still taking place for residents and staff?
- 03How do you make sure staff use protective equipment correctly when supporting residents?
- 04What was the outcome of the most recent full inspection covering care, staffing and management?
This was a targeted inspection of infection prevention and control only; the home was inspected but not rated and the other areas were not assessed. This explanation was written from the published report of 4 September 2020 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, May 2018
Pelham Grove Care Home is rated Good; inspectors found kind, safe and responsive care, with some fire safety and planning points to follow up.
Inspectors visited on 13 and 20 March 2018. The first visit was unannounced. They spoke with people living in the home, relatives and staff, observed care, and checked medicines, care records, recruitment, training, safety and quality checks.
The home was rated Good in all five areas: safe, effective, caring, responsive and well-led. People said they felt safe and valued the staff. Inspectors found enough staff, well-managed medicines, suitable care plans, support with health needs, enjoyable activities and respectful care.
There were some points to improve or keep under review. These included unclear progress on fire safety work, making emergency evacuation plans easier to follow, creating an overall staff training plan and considering dementia-friendly design during refurbishment.
Kind and respectful staff
People said staff were kind and attentive. Inspectors saw staff protecting privacy, explaining care and making time for conversation.
“Throughout the inspection we observed staff chatting with people and spending time engaging with them socially as well as meeting their personal care needs.” from the report
Safe medicines and staffing
Medicines were stored, recorded and given safely. Inspectors also found enough staff to respond without rushing, and permanent staff meant people had familiar carers.
“Medication was managed so that stocks were kept to a minimum and people had their medication available.” from the report
Individual activities
The activities coordinator knew people's interests and arranged different activities, trips and opportunities for company.
“Activities were arranged to meet people's choices and hobbies.” from the report
Good care planning
People had assessments, risk assessments and care plans that described their needs, preferences and the support staff should provide. These were reviewed regularly.
“Care plans had been reviewed regularly to check the information was up to date and accurate.” from the report
Good staffing response
People and staff said staffing levels were suitable. Inspectors saw staff respond to people's care needs promptly and without rushing.
“Throughout the two days of our inspection we saw that although staff were busy they had time to respond to people's care needs in an unrushed and timely manner.” from the report
Fire safety follow-up
seriousA fire service letter had identified improvements, but inspectors could not confirm that all the work had been completed. After the inspection, the registered manager said a company had been booked to carry out the work.
“A letter from the fire service in May 2017 identified improvements were needed for fire safety.” from the report
Emergency evacuation plans
needs fixingThe evacuation information had been combined into one plan, which inspectors felt could be difficult to follow in an emergency. Work had started on individual plans during the inspection.
“These had been compiled into one overall plan which may not be easy to follow in an emergency.” from the report
Staff training planning
needs fixingStaff had completed relevant training, but there was no overall training plan or assessment to identify and plan future training needs.
“No overall training plan or assessment was in place.” from the report
Refurbishment design
minorSome refurbishment was still taking place. Inspectors said the new dining room floor could be confusing for people with poor eyesight or dementia.
“new dining room floor was highly patterned and could be confusing for people with poor eyesight or who are living with dementia to walk across.” from the report
- 01Have all the fire safety improvements identified in the May 2017 fire service letter now been completed, and can you show us the latest checks?
- 02Are individual personal emergency evacuation plans now in place for everyone who needs one?
- 03What overall staff training plan and assessment have you introduced since the inspection?
- 04How will you make sure future refurbishment supports people living with dementia or poor eyesight?
- 05How are people's activity choices, health needs and changing care needs reviewed?
This was a first comprehensive inspection of the home since the current provider registered it in February 2016, and it covered all five CQC questions. This explanation was written from the published report of 30 May 2018 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Pelham Grove Care Home
Each visit the CQC has published, newest first, back to the day the home was registered.
- September 2020Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- May 2018GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2016
Registered with the Care Quality Commission on 22 February 2016.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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