CQC report explained · a residential care home
What the CQC found at Pilgrim Wood Residential Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People felt safe and inspectors found enough staff, suitable recruitment checks, safe medicines management and improved fire safety. Accident and incident reviews were being used to reduce the risk of similar events.
- Effective?
- Good
- This area was not covered by this focused inspection. Its previous rating was used when calculating the overall rating.
- Caring?
- Good
- This area was not covered by this focused inspection. Its previous rating was used when calculating the overall rating.
- Responsive?
- Good
- This area was not covered by this focused inspection. Its previous rating was used when calculating the overall rating.
- Well-led?
- Good
- Inspectors found better records, effective quality monitoring, improved management oversight and plans for regular staff supervision. People, relatives and staff had opportunities to give their views.
What inspectors found, October 2021
Pilgrim Wood Residential Home is rated Good; inspectors found safe care, stable staffing and stronger management after earlier problems.
This was an unannounced focused inspection on 16 September 2021. One inspector spoke with people, relatives, staff and a healthcare professional. They observed care and checked care plans, risk assessments, medicines records, accident records, training records and quality audits.
The home was rated Good for Safe and Well-led. People said they felt safe, staff were available and knew their preferences. Inspectors found improved fire safety, safe medicines systems, suitable infection control and better records and management oversight.
The previous inspection, published in December 2019, rated the service Requires Improvement and found two breaches. This inspection found enough improvement for the home to be no longer in breach. The overall rating changed to Good, but the other three areas were not examined during this visit and their previous ratings were carried forward.
Safer fire arrangements
Fire safety had improved since the previous inspection. The alarm system had been replaced and work needed to meet fire safety rules had been completed.
“Action had been taken to improve standards of fire safety.” from the report
Safe medicines
Medicines were stored, ordered and disposed of appropriately. Staff were trained and their competence was checked before they administered medicines.
“There were no gaps in recording on the sample of medicines administration records we checked.” from the report
Better care records
Care plans had become more personal and detailed. They included information about people's needs, risks and how staff should provide support.
“Care plans were person-centred and set out what people could do for themselves.” from the report
Improved management oversight
The management team had introduced quality checks and recruited two deputy managers. A staff supervision programme had also been planned.
“Effective quality monitoring systems had been implemented and two deputy managers had recently been recruited to strengthen the home's management team.” from the report
Inspectors raised no specific concerns in this report.
- 01How are the new quality monitoring checks used to find and fix problems now?
- 02How often are staff receiving the planned one-to-one supervision sessions?
- 03When was the most recent fire safety review, and what actions followed it?
- 04How are accident and incident reviews used to update people's care plans or reduce risks?
- 05What were the findings of the external medicines audit requested from the supplying pharmacy?
This was a focused inspection of Safe and Well-led only; the other three key question ratings were carried over from the previous comprehensive inspection. This explanation was written from the published report of 5 October 2021 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 2019
Rated Requires Improvement; inspectors found kind and responsive care, but fire safety and management systems were not reliable enough.
This was an unannounced inspection on 10 October 2019. Inspectors spoke with people living at the home, visitors and staff. They reviewed care records, medicines, staff files, accident records and quality checks.
People generally received kind, respectful care. Staff understood people's needs, supported their health, provided activities and responded to complaints. Medicines, staffing, recruitment, cleanliness and infection control were managed safely.
However, urgent actions from a fire risk assessment had not been completed. Accident and incident records were not reviewed for lessons, and some records were disorganised or out of date. The home was still in breach of Regulations 12 and 17.
The overall rating was Requires Improvement. Effective, Caring and Responsive were rated Good. Safe and Well-led remained Requires Improvement. Effective had improved from Requires Improvement at the previous inspection, but the overall rating had not improved.
Kind and respectful care
People were treated with dignity and staff knew their needs and preferences. Relatives described the home as friendly and welcoming.
“People were supported and treated with dignity and respect and involved as partners in their care.” from the report
Safe medicines practice
Inspectors found medicines were received, stored, given and disposed of safely. Medicines records checked were accurate and up to date.
“The sample of medicines administration records we checked was accurate and up-to-date.” from the report
Health and nutrition support
Staff monitored people's health, arranged healthcare appointments and supported people to eat and drink. Dietary needs and preferences were shared with catering staff.
“Staff supported people to maintain adequate hydration by offering drinks throughout the day.” from the report
Activities and personal interests
The home offered daily activities and used people's individual interests to plan events and outings. Links with local groups helped people stay involved.
“Activities were arranged according to people's individual interests.” from the report
Improved communication
Relatives said communication had improved since the new manager joined. Meetings and surveys gave people, families and staff opportunities to share views.
“At this inspection, relatives said the communication from the provider and registered manager had improved.” from the report
Fire safety actions outstanding
seriousA fire risk assessment had identified urgent actions, including replacing a locked door on an evacuation route. These actions were still outstanding during the inspection.
“Some of these actions had been categorised as 'urgent' and as requiring action within one month.” from the report
Accidents were not reviewed
seriousManagers recorded accidents and incidents but did not review them to identify ways of preventing similar events. This included a fall that caused a skin tear.
“accident and incident records were not reviewed by the management team to identify any learning” from the report
Weak record and audit systems
needs fixingImportant information was held in different places, with some records out of date. Quality checks did not make sure identified problems were corrected.
“Some records were out-of-date and no longer relevant, which made it difficult to locate accurate, up-to-date information.” from the report
Staff supervision was overdue
needs fixingSome staff had not received one-to-one supervision for at least six months. Further supervision sessions had been scheduled after this was raised.
“some staff had not received one-to-one supervision for at least six months at the time of our inspection.” from the report
Incident not reported to CQC
needs fixingThe provider did not notify CQC about an incident involving one person entering another person's bedroom without consent, although the local safeguarding authority had been told.
“The provider had informed the local safeguarding authority of this event but had failed to notify CQC.” from the report
- 01Have all actions from the April 2019 fire risk assessment been completed, including the door on the evacuation route?
- 02How are accidents and incidents now reviewed, and what changes have been made as a result?
- 03Where are care, risk and safety records kept, and how do you check that they are current and consistent?
- 04How often will the staff caring for my relative receive one-to-one supervision?
- 05How do you make sure incidents that must be reported are notified to CQC and other relevant bodies?
This was an unannounced planned inspection of the whole care home, covering all five CQC questions and both the premises and care provided. This explanation was written from the published report of 14 December 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 Pilgrim Wood Residential Home
4 rated inspections over 5 years: the service has held its Good rating throughout.
- October 2021Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Pilgrim Wood Residential Home →
- December 2019Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
Read what inspectors found at Pilgrim Wood Residential Home →
- November 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- December 2011
Registered with the Care Quality Commission on 1 December 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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