CQC report explained · a nursing home
What the CQC found at Pilgrims Way Care Home with Nursing
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, December 2023
Pilgrims Way Care Home with Nursing was rated Good overall, but inspectors found medicine and management checks needed improvement.
This was an unannounced comprehensive inspection on 23 October 2023. Inspectors and Experts by Experience spoke with people living in the home, relatives and staff. They observed care and checked care plans, medicine records, recruitment files, training records and management audits.
The home was rated Good for Safe, Effective, Caring and Responsive. People generally felt safe and said staff were kind, respectful and knew them well. Inspectors found detailed care plans, enough staff, safe infection control, support with food and healthcare, and activities that reflected people's interests.
Well-led was rated Requires Improvement. A new registered manager had introduced new quality checks, but these were not yet fully established. The checks had missed medicine recording problems, expired blood sugar testing strips, weaknesses in recruitment records and a lack of reliable monitoring of call bell response times.
Detailed risk planning
Inspectors found clear and up-to-date risk assessments covering issues such as falls, skin damage and choking. Staff received useful information about how to provide safe care.
“Risk assessments were clear, up to date and contained a high level of detail.” from the report
Kind and respectful care
People said staff were kind and respectful. Inspectors observed patient and reassuring interactions, with staff giving people time to communicate.
“Staff were patient with people and gave them time to respond to questions, talking with them at their own level, using gentle tones, and offering reassurance.” from the report
Personalised support
Care plans recorded people's preferences, communication needs, food choices and spiritual or religious needs. People had choices about routines, clothes and where they ate.
“Care plans were personalised and reflected people's preferences in all areas.” from the report
Skilled staff and healthcare links
Training was up to date, including specialist training. Nurses worked with doctors, hospice staff and other health professionals to support people's health needs.
“Specialist training had been provided in areas such as Parkinson's Disease and End of Life care.” from the report
Medicine checks
seriousInspectors found that medicine patch and injection sites were not recorded to show they were rotated. Blood sugar monitoring strips for people using insulin were out of date, although inspectors found no evidence of harm.
“Medicines were not always managed safely in line with national guidance.” from the report
Quality monitoring
needs fixingAudits did not identify several problems found during the inspection. New quality systems had been introduced but were not yet fully established.
“The provider's systems did not always effectively monitor the quality of care provided to drive improvements.” from the report
Call bell monitoring
needs fixingSome people and relatives said they waited a long time for call bells to be answered. The home did not have a reliable system to monitor response times.
“Some people and relatives told us they waited a long time for staff to respond to their call bell.” from the report
Recruitment records
needs fixingSome recruitment files did not show that gaps in employment history had been explored, and interview records were missing. The provider took action and later sent interview notes to inspectors.
“The provider did not always operate safe recruitment processes.” from the report
Feedback and communication
minorMost people had not been asked for their views through meetings or surveys. A previous survey had not been analysed, and some relatives said communication with managers could be better.
“Most people told us they had not been asked their opinion of the service, or for feedback, either through meetings or via a survey.” from the report
- 01How do you now record and check that medicine patch and injection sites are rotated?
- 02How do you check the expiry dates of blood sugar monitoring strips and other important monitoring products?
- 03How are call bell response times monitored, and what happens if people wait too long?
- 04What changes has the new registered manager made to quality audits, and how do you know they are working?
- 05How are feedback from people and relatives now collected, analysed and turned into an action plan?
This was an unannounced comprehensive inspection covering all five key questions, with infection prevention and control also checked under Safe. This explanation was written from the published report of 6 December 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 2018
Pilgrims Way Care Home with Nursing was rated Good; inspectors found safe, kind and person-centred care, and the previous lifting-sling recommendation had been acted on.
This was an unannounced comprehensive inspection on 15 November 2018. Inspectors spoke with people living in the home, relatives and staff. They observed care, reviewed seven care records and checked staffing, training and management records.
The home was rated Good overall and Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough nursing and care staff, safe medicines practice, suitable care planning and support for people's health, nutrition and personal choices.
People were treated with kindness and their privacy and dignity were respected. The home offered activities, listened to complaints and used audits, meetings and feedback to monitor and improve the service.
The previous inspection in March 2016 had also rated the home Good overall, although Safe had required improvement because of a recommendation about lifting slings. Inspectors found that this recommendation had been acted on.
Safe staffing and medicines
Inspectors found enough nursing and care staff to meet people's needs. Nurses gave medicines safely and kept accurate records.
“People received their medicines in a safe way, from nurses that had been trained and had their competency assessed.” from the report
Kind and respectful care
Staff were observed offering reassurance and emotional support. They respected people's privacy, dignity, choices and independence.
“People were treated with kindness and compassion. Staff understood the importance of promoting and respecting people's privacy and dignity.” from the report
Personalised support
Care plans included people's preferences, interests and health needs. Staff used this information to provide care in the way people wanted.
“People received a person-centred service that was responsive to their needs.” from the report
Listening and improvement
The home provided ways for people and relatives to give feedback. The management team used audits and action plans to monitor quality.
“People and their relatives were involved in developing the service.” from the report
Inspectors raised no specific concerns in this report.
- 01What changes were made after the previous recommendation about lifting slings, and how are slings checked now?
- 02How will you assess and meet my relative's specific nursing, mobility, dietary and hydration needs?
- 03What effect did the refurbishment of one building have on residents, and has the work now been completed?
- 04How are staffing levels reviewed when residents' needs change?
- 05How will my relative's activity preferences, privacy and independence be recorded and reviewed?
This was an unannounced comprehensive inspection covering all five key questions, with observations of care, discussions with people, relatives and staff, and reviews of care and management records. This explanation was written from the published report of 13 December 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 Pilgrims Way Care Home with Nursing
4 rated inspections over 8 years: the service has improved, from Requires improvement to Good.
- December 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Pilgrims Way Care Home with Nursing →
- December 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Pilgrims Way Care Home with Nursing →
- May 2016Goodup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2015Requires improvementSafe: InadequateEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- June 2013
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- October 2011
Report published without a new overall rating.
- March 2011
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 26 November 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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
39 live-in carers within about an hour of Kent
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 £980 to £1,260 a week. 33 can care for a couple. 12 years' experience on average.
“Always on time and with a lovely smile for my mum. Theresa is kind and sensitive to my mum's needs.”
“Irene was a very kind and empathetic carer who knew just the right words to say to put a smile on my face.”
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.