CQC report explained · a residential care home
What the CQC found at Pelham Manor
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, January 2023
Pelham Manor is Requires Improvement; inspectors found kind, personalised care, but legal safeguards, infection control, recruitment and management oversight needed improvement.
This was an unannounced inspection over 31 October and 1 November 2022. One inspector spoke with two people, four relatives and five staff. They observed care and reviewed care, medicine, recruitment, training and management records.
The home was rated Requires Improvement overall. Safe, Effective and Well-led were also Requires Improvement. Responsive was Good. Inspectors found kind care, good communication and support with activities, healthcare, food and medicines.
There were important shortfalls. Mental capacity checks and legal safeguards were not always handled correctly. Infection control guidance was not followed, agency staff checks were incomplete, and records and quality checks were not reliable. This was the second Requires Improvement rating, following the same rating published in June 2019.
Communication support
Staff used individual communication plans, pictures, sounds, body language and Makaton to help people express themselves and understand information.
“People had individual communication plans that detailed effective and preferred methods of communication.” from the report
Activities and community life
People were supported to follow their interests, attend day services, use local shops and take part in activities such as swimming, walks and arts and crafts.
“People were supported to participate in social and leisure interests and to stay in regular contact with family and friends.” from the report
Medicines and nutrition
Staff were trained and checked as competent to give medicines. People were also supported with food and drink according to their individual needs.
“People were supported by staff who followed systems and processes to administer and record medicines safely.” from the report
Legal safeguards
seriousMental capacity assessments and best-interest decisions were not always recorded for specific decisions. One person's restriction continued without a timely renewal application for their legal safeguard.
“The provider had failed to consistently follow the principles of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards.” from the report
Infection control
seriousThe home did not follow government guidance about face masks for care workers and visitors, and had not assessed the risks of taking a different approach.
“The provider had failed to assess the risk of, prevention and spread of infections.” from the report
Staff recruitment checks
seriousThere were enough staff, but records for most agency staff did not show their training, skills or experience. Some permanent staff files were also incomplete.
“The provider had failed to ensure the safe recruitment of staff.” from the report
Care information and oversight
seriousQuality checks did not consistently identify and fix problems. Important care information was held in places that care staff could not access, and some records were incomplete or out of date.
“The provider had failed to operate an effective quality assurance system and for records about peoples care and treatment to be easily assessible and complete.” from the report
Family feedback
needs fixingPeople and relatives were not consistently asked for their views, so their feedback could not always be used to improve the service.
“The provider had failed to consistently seek and act on feedback from people who used the service and their representatives.” from the report
Access to health information
needs fixingHealth information was being moved to a new system. Only one person's records had been transferred, and some medicine information was out of date, creating a risk of delays or mistakes.
“Information about people's health needs and how best to support people was not always easy to access.” from the report
- 01What has been done to ensure every restriction is covered by the correct mental capacity assessment, best-interest decision and Deprivation of Liberty Safeguard?
- 02How are face-mask requirements for staff and visitors now being managed and checked?
- 03How do you check the training, skills and experience of agency staff before they work in the home?
- 04Can care staff now quickly access complete and up-to-date care, health and medicine information?
- 05How are people and relatives being asked for feedback, and how is the home acting on what they say?
The report gives ratings for Safe, Effective, Responsive and Well-led; it does not give a Caring rating, and says ratings for key questions not inspected carry over from the previous inspection. This explanation was written from the published report of 19 January 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, June 2019
Pelham Manor was rated Requires Improvement; inspectors found kind, personalised care but weaknesses in safety checks, legal decision records and oversight.
The inspection was unannounced and took place on 5 March 2019. One inspector spoke with people, relatives, staff and the manager. They observed care and checked records, medicines, staffing, training, risks and complaints.
People were treated kindly and supported to make choices, communicate, stay active and build independence. The home was clean, staff knew people well, and relatives were positive about the care.
However, some safety checks were incomplete. Fire alarm and fire drill records did not show enough detail. Water temperatures and shower head cleaning were not always checked as planned. Records of some best-interest decisions did not show who had been involved.
The overall rating was Requires Improvement. Safe, Effective and Well-led were rated Requires Improvement. Caring and Responsive were rated Good. This was lower than the previous Good rating from the inspection on 2 August 2016.
Kind and respectful care
Inspectors saw staff speaking calmly and patiently. People appeared comfortable with staff, and relatives described the care as kind and respectful.
“We observed people being treated with kindness and compassion.” from the report
Personalised communication
Staff knew how people communicated and used pictures, objects, stories and electronic devices to help people express their views.
“People were supported to express their views in a way which suited them.” from the report
Choice and independence
People were encouraged to make day-to-day choices, take part in daily tasks, prepare food and use the community.
“People were encouraged to become independent.” from the report
Activities and community life
People took part in day services, sensory activities, exercise, shopping and holidays. Staff supported people to stay active and engaged.
“People were supported to access activities such as attending day services, sensory activities, exercise activities such as swimming and trampolining, going shopping or going on holiday.” from the report
Medicines administration
Medicines were administered as prescribed and staff followed good practice when supporting people. However, some stock records were difficult to track.
“Medicine administration records (MARS) were complete and accurate and people received their medicines as prescribed.” from the report
Incomplete safety checks
seriousFire safety checks did not identify which alarm points had been tested, and fire drill records did not show which staff had taken part. Water temperatures and shower head cleaning were also not always recorded as required.
“The failure to manage risks to people's health and welfare was a breach of Regulation 12 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Fire risk actions outstanding
seriousOne action from the fire risk assessment, involving warning signs where barbecue gas was stored, had not been completed. Personal evacuation plans also did not mention flammable paraffin-based creams.
“One action to fix appropriate warning signs to the shed where BBQ gas was stored had not been completed.” from the report
Best-interest records
needs fixingBest-interest meetings had taken place, but the records did not show which relatives or professionals had been involved in the decisions.
“Best interest decision records did not show who had been involved in the decision making process.” from the report
Checks did not find problems
needs fixingThe home had audits and quality checks, but these had not picked up the weaknesses in risk management found by inspectors.
“The audits and checks were robust but had not captured the issues relating to risk management we had identified.” from the report
Medicine stock records
needs fixingSome medicine records did not show the amount carried forward from the previous month. Different stock-counting forms made it harder to track medicines.
“This made it difficult to track medicines.” from the report
- 01Have all fire alarm points now been tested and recorded by location?
- 02Do fire drill records now show which staff have taken part, and has every staff member completed a drill?
- 03How often are water temperatures and shower heads checked now, and can we see the recent records?
- 04How do you record who was involved in best-interest decisions for people who cannot make a particular decision?
- 05What changes have been made to the audits so they identify safety problems before they are missed?
This was an unannounced inspection of the care home, covering accommodation and care, with ratings given for all five CQC questions. This explanation was written from the published report of 1 June 2019 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 Manor
3 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- January 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementResponsive: GoodWell-led: Requires improvement
- September 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 23 December 2010.
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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