CQC report explained · a residential care home
What the CQC found at Pelham House Residential Care Home with Dementia
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Medicines were not always stored, recorded or administered safely. Risk assessments and safeguarding processes were also inconsistent.
- Effective?
- Good
- This key question was not inspected during this visit. Its rating was carried over from the previous inspection.
- Caring?
- Good
- This key question was not inspected during this visit. Its rating was carried over from the previous inspection.
- Responsive?
- Good
- This key question was not inspected during this visit. Its rating was carried over from the previous inspection.
- Well-led?
- Requires improvement
- The provider's checks did not reliably identify or fix problems with medicines, risks, safeguarding or agency staffing.
What inspectors found, July 2023
Requires Improvement; inspectors found unsafe medicines, weak risk management and poor oversight, although people described staff as kind.
This was an unannounced focused inspection on 20 March 2023. Three inspectors observed the home, spoke with people, relatives, staff and health professionals, and checked care, medicines, staff and management records.
The home was not always safe. Medicines were sometimes left unlocked and unattended. Risk assessments did not always give staff enough guidance, including for diabetes, catheter care and periods of distress. Potential safeguarding incidents had not always been reported or investigated properly.
The home was also not well-led. Quality checks had failed to find or fix important problems. The overall rating was Requires Improvement, and this was the fourth consecutive inspection with that rating. The report says the provider had to send CQC an action plan, and the local authority later reported that the provider was engaging with it.
Kind staff
People and relatives spoke positively about the care and said staff were caring, kind and patient.
“I think the staff are caring and look after me well. They are all very kind and patient” from the report
Infection control
Inspectors were assured that infection prevention arrangements, including PPE, visitors and outbreak response, were effective.
“We were assured that the provider was using PPE effectively and safely.” from the report
Safe recruitment
New staff had the required recruitment checks, including checks through the Disclosure and Barring Service.
“New staff were recruited safely. All necessary checks were completed, including Disclosure and Barring Service (DBS) checks.” from the report
Personalised care
Care plans included people's preferences and information about how they wanted personal care to be provided.
“People received personalised care that met their needs.” from the report
Medicines left unsecured
seriousThe medicine storage room was left unlocked and unattended. Some medicines were also left accessible on a worktop, creating a risk that people could take medicines not prescribed for them.
“Medicines were not stored safely because staff had left the medicine storage room unlocked and unattended.” from the report
Health risks not managed consistently
seriousRisk plans did not give enough guidance for catheter care or diabetes monitoring. Blood glucose records were inconsistent, and staff did not always have clear instructions about what to do when health worsened.
“Risks were not assessed effectively, and risks practically mitigated to ensure people were kept safe.” from the report
Safeguarding concerns not escalated
seriousThree incidents involving unexplained bruising and scratches had not been properly escalated or investigated. The provider also lacked consistent analysis of incidents and possible patterns.
“The failure to ensure there were effective systems to protect people from abuse and improper treatment” from the report
Weak quality checks
needs fixingAudits and action plans did not reliably identify or resolve problems. The provider was not aware that some actions had not been completed.
“Systems were not effective in in assessing, monitoring and improving the quality and safety of the service.” from the report
Agency staff oversight
needs fixingThe provider did not always know which agency staff were working or whether they had the right skills and experience. The provider said it would change agency and improve checks after the inspection.
“The provider did not have systems in place to ensure that agency staff were appropriately skilled to enable effective deployment of staff.” from the report
- 01How are medicines now kept locked and unattended access prevented?
- 02How do you check that medicines delivered to the home are recorded promptly and that delayed or refused doses are communicated between floors?
- 03What written guidance is now in place for diabetes monitoring and catheter care?
- 04How are unexplained injuries and other possible safeguarding concerns reported, investigated and reviewed for patterns?
- 05How do you check the identity, training and experience of agency staff before they work in the home?
This was a focused inspection of Safe and Well-led only; the other key-question ratings were carried over from the previous inspection. This explanation was written from the published report of 19 July 2023 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, December 2022
Rated Requires Improvement; inspectors found unsafe medicines practice, infection control concerns and weak checking systems, although people felt safe and cared for.
This was an unannounced inspection on 27 October 2022. Inspectors spoke with people, relatives and staff, observed care, and checked care plans, medicines records, staff files and management records.
The home was not always safe. Medicines were sometimes given late, records were signed after several medicines had been given, and staff did not always clean their hands or change gloves between tasks. Personal care information was also displayed outside some bedroom doors.
There were positive findings. Staffing levels were sufficient, call bells were answered promptly, risks such as falls and fire safety were managed, and people said staff were kind and caring. The home was working within the principles of the Mental Capacity Act.
The overall rating remains Requires Improvement, as do Safe and Well-led. This is the third consecutive inspection with this rating. The provider must send an action plan, and CQC will monitor progress.
People felt safe
People said they felt safe, and relatives also said people were safe at the home. Staff knew how to report possible abuse.
“People were safe living at the home.” from the report
Enough staff
Inspectors found enough trained staff to meet people's needs. People said call bells were answered quickly.
“There were sufficient, trained staff on duty to meet people's care and support needs.” from the report
Kind and caring staff
People and relatives were positive about the care. Staff were described as kind, caring and patient.
“People were supported by kind and caring staff.” from the report
Risk management had improved
The home had improved its monitoring after head injuries and had clearer guidance about some health conditions. Environmental risks, falls and nutrition were assessed.
“Actions had been taken following the last inspection and improvements had been made.” from the report
People's choices
People were supported to make choices and were involved in activities and decisions about their daily lives. Their religious and communication needs were recorded.
“People and staff were involved in developing the service.” from the report
Medicines were not always safe
seriousSome medicines were given late, including medicines that had to be taken at specific times. Medication records were not signed immediately after each person received their medicines.
“The administration of medicines was not managed safely.” from the report
Infection control practice
seriousStaff did not always sanitise their hands between people. One staff member wore the same disposable gloves while handling walking frames and serving food.
“This put people at risk of the spread of infection.” from the report
Checks did not find problems
seriousAudits had improved but did not identify the unsafe medicines practice or inconsistencies in care plans. The provider remained in breach of good governance requirements.
“Systems were not effective in identifying the inconsistency of information contained within some care plans or the administration of medicines.” from the report
Private information was displayed
needs fixingSome notices outside bedrooms described people's personal care needs in a way inspectors considered public, undignified and disrespectful. The manager agreed to remove them.
“This information included detail about people's personal care needs and should not have been made public.” from the report
- 01What has changed to make sure every medicine is given at the prescribed time and the medication record is signed immediately afterwards?
- 02How are staff now checked to make sure they sanitise their hands and change disposable gloves between people and activities?
- 03What action has been taken to remove personal care information from outside bedroom doors and protect people's privacy?
- 04How are care plan errors now found and corrected across every relevant section of the electronic system?
- 05What progress has been made on the action plan requested by CQC, and how is this being monitored?
This was a focused inspection of Safe and Well-led, including infection prevention and control; the other key question ratings were not inspected and the overall rating used previous ratings. This explanation was written from the published report of 7 December 2022 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 House Residential Care Home with Dementia
6 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- July 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Pelham House Residential Care Home with Dementia →
- December 2022Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
Read what inspectors found at Pelham House Residential Care Home with Dementia →
- August 2021Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- September 2019Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- July 2017Goodstayed GoodSafe: GoodWell-led: Good
- November 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2014
Report published without a new overall rating.
- February 2014
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- June 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 28 January 2011.
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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28 live-in carers within about an hour of West Sussex
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £1,020 to £1,170 a week. 23 can care for a couple. 11 years' experience on average.
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.