20 March 2023
During an inspection looking at part of the service
People's experience of using this service and what we found
Medicines were not always administered or stored safely. The clinical room and enclosed cupboards where medicines were stored were left unlocked and unattended. This meant there was a risk of people consuming medicines that they were not prescribed. There were some risk assessments in place, however risks were not always properly assessed or didn’t contain enough information to enable staff to support people appropriately.
Risks to people were not always managed effectively, including people’s health needs. These included that people lived with diabetes and used a catheter.
Staff had not always recognised potential safeguarding incidents and lack of management oversight meant these had not been reported to the local authority in line with the providers policy. Some people told us they felt safe. One person said, "I do feel safe. There are enough people that make sure I am. If I needed anything I, would ask”.
There were sufficient staff deployed, however, the provider did not knew what staff were being sent from the agency or what skills and experience they had. This meant that there was a risk of staff being deployed to areas of the service without having the necessary skills to support people appropriately.
There was a lack of oversight of the quality and safety of the service by the provider. There were not adequate systems and processes in place to monitor the quality of care or sufficiently robust to identify any shortfalls or concerns. .
People told us positive things about the care they received from staff. One person said, "I think the staff are caring and look after me well. They are all very kind and patient".
People gave feedback about the service using surveys and questionnaires, but people said they hadn’t completed them for a while.
People told us that they used their call bells if they needed assistance and these were responded to in a timely fashion.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was requires improvement (published 6 December 2022). The service remains rated requires improvement. This service has been rated requires improvement for the last four consecutive inspections.
Why we inspected
We received concerns in relation to the care people received. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.
The inspection was also prompted in part by notification of an incident following which a person using the service died. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of the incident. However, the information shared with CQC about the incident indicated potential concerns about the management of risk of specific health needs. This inspection also examined those risks.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively
For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Pelham House Residential Care Home with Dementia on our website at www.cqc.org.uk.
The overall rating for the service is requires improvement based on the findings of this inspection.
Since the inspection, the local authority has carried out a number of quality assurance visits and to date, report that the provider has engaged with them in addressing the shortfalls that are set out in this report.
You can see what further action we have asked the provider to take at the end of this full report.
Enforcement
We have identified breaches in relation to safe care and treatment, safeguarding and good governance.
Please see the action we have told the provider to take at the end of this report.