Pilgrims Way Care Home with Nursing

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

The service remains safe overall. However, on the day of our on-site assessment not all areas of the building were safe. Staff had not made sure doors were closed and locked to rooms where hazardous substances were stored and where building works were being completed. Potential risks to people’s health were assessed and staff had guidance to support people safely. Incidents and accidents were recorded and analysed, any safeguarding concerns had been reported to the local authority. There were enough staff to support people in the way they preferred. Staff had received training appropriate to their role and people received their medicines as prescribed.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Relatives told us they were kept informed of any incidents or concerns. When they raised concerns action was taken and the incidents had not happened again. A relative told us, “I had to mention that (relative) was getting meals that needed to be cut up into smaller sized pieces for them to eat. After mentioning it, it was dealt with and there hasn’t been an issue since.”

The management team told us they had systems in place to record, monitor and analyse incidents, “We have CCTV in place (communal areas), and I can check the cameras from my home through my mobile phone. We have incident and accident forms online, which I print out and fill in. These can then be scanned into the care plan and a hard copy kept on file. I check the person is safe, inform the GP or health professional and notify the family.” Staff told us they knew how to report and accidents or incidents and felt confident to do so. Staff told us if there was an incident they would report to the nurse in charge of the shift and then record it on the incident record form. One nurse explained the procedure they followed when an incident happens. They told us if someone had a fall, they would assess the person and decide if the person needed to go to the hospital or needed to be seen by the GP. They told us their relatives would be informed. The incident is then discussed during handover, so all staff were aware and know what to do and how to care for the person. The person’s risk assessment would be reviewed and updated.

Records of incidents and accidents and when things go wrong were maintained. Monthly audits were done to identify patterns and trends. There were no staff team meetings, residents or relative meetings taking place. The new deputy manager told us they have started monthly team meetings. These meetings will focus on incidents and accidents and any concerns about the residents’ care. Handover meetings are currently used to share concerns about people’s care and any learning from incidents and accidents.

People were supported to maintain their health and attend appointments both inside and outside of the service. Where routine health checks were undertaken, people had support from people they knew well to understand what was happening. Comments included, “The chiropodist comes to see me as I am diabetic, and the staff make sure my nails are clean and trimmed.” A relative told us, “I never have to ask how she is. Any slight changes and the nurse telephones me straight away, they are very proactive and keep me updated all the time.”

The management team told us they worked with others to resolve problems and make improvements. The service had maintained regular contact with the local authority commissioning team and social workers. They also worked closely with the GP, diabetic team, chiropody services, physiotherapy, and the dietician and SALT teams. Staff told us they made sure people's information was given to the ambulance team if people need to go to the hospital or other services. Staff told us they supported people to take along personal items as such as hearing aids, glasses, and dentures they may need. Staff told us they shared relevant information about people during handovers, for example, if their medication had changed or if someone wasn’t feeling well. The nurses explained they reviewed people's discharge summaries and checked their medications when they returned to the service after admission from hospital.

Healthcare professionals gave us positive feedback. Comments included, “Instantly, I have received responses when I enquire about changes made. All my emails are always acknowledged.” And “All referrals are picked very promptly. Also, when I ask the GP to complete referrals, the nursing staff have been very prompt to get it done.”

The provider worked with people and partners including the local authority care managers and health professionals to establish and maintain safe systems of care. Safety was managed, monitored and assured. When people were supported to go to hospital, either through routine and planned admission, emergency admission or consultation day visits, hospital passports were in place. A hospital passport gives hospital staff important information about them and their health when they go to hospital. This included information such as people’s, medical history, medication list, GP and next of kin details.

People told us they felt safe living at the service and were confident staff acted to keep them safe. One person told us, “Everything that goes on here is for the purpose of keeping us all safe”. Another told us, “I feel safe because I am not on my own.” And “I know people are there to help me.”

Staff understood what safeguarding was and told us they had received the appropriate training in adult safeguarding. Staff described the signs and types of abuse including the action they would take if they had concerns. Staff knew how to raise concerns and were confident the management team would take action. Staff were also aware of how to raise concerns with outside agencies if their concerns had not been acted on. The deputy manager told us they were in the process of arranging additional face to face safeguarding training for staff.

The general environment of the home was calm and relaxed. People who could were making their way around the service independently and unrestricted. Most people living at the service required staff assistance to mobilise either with a frame or wheelchair. No one was observed to be in distress, and staff were visible in communal areas; always at least one staff member in the main lounge. Communication with people was kind and respectful and staff responded appropriately to people’s needs, for example, if they required the toilet or wanted to move to another room. People appeared comfortable with staff and trusting of their support.

The provider had a safeguarding policy and procedures in place. There were posters at the entrance of the service giving details of the process. The provider shared safeguarding concerns with the local authority, CQC and the police where necessary.

People told us staff supported them to manage the risks to their health and wellbeing. People told us that staff gave them time when supporting them with their care needs. Comments included, “Staff are patient, and they do give me the time I need.”

The deputy manager told us, “Risk assessments are in place in people’s care plans, updated monthly or sooner if there are changes, and we liaise a lot with external health care professionals. We also support staff with shadowing more experienced staff.” Staff told us they knew people well. Staff understood the health risks of people and could explain the signs/symptoms of certain conditions such as diabetes. Staff told us, “I follow the care plan because it’s very clear what to do. For example, someone with diabetes might become sleepy or sweaty or thirsty. I record their presentation in their daily record and tell the nurse who carries out all the observations, checks blood sugar levels, and we keep a close eye on them and keep their family updated.” When people became distressed and emotional, staff knew how to manage these situations by responding promptly, giving people time, and by providing respectful reassurance. Staff described measures in place to protect people who were at risk of falling such as low-rise beds and sensor mats and bed rails.

People were supported to move around the service safety and were supported to spend time where they chose. We observed the lunchtime meal, kitchen staff were aware of people’s allergies and dietary needs. People were given food and fluid in a consistency which was in accordance with their assessed needs, including diabetic, soft and gluten free diets. The food was well presented, and people seemed to be enjoying the mealtime experience. Staff checked on people eating in their own rooms, supporting them with their meals and to make sure they were safe. The service used equipment to help maintain people’s safety. Staff were observed carrying out moving and handling tasks safely. They followed procedures stated on the individual’s care plans such as the equipment to be used with the number of staff required for safe moving and handling. People had their mobility aids within reach.

People’s care plans were accurate, person centred and complete with appropriate risk assessments. For example, some people received their diet through a tube directly into their stomach, there was information on how to manage the site, keep it clean, and how to maintain the equipment. Care plans were reviewed monthly unless required sooner. All care plans used a traffic light system to prompt staff to review and update areas of the care plan in a timely manner.

People and relatives told us they were happy with the environment and their rooms were clean and kept tidy. People told us, “The home is clean; they are always keeping the place clean.” A relative told us, “It’s always clean and doesn’t smell.”

We spoke with the provider about fire risks. The service had been inspected by the fire service in March 2023 and the necessary remedial actions had been completed. Staff told us they felt confident with fire procedures. Staff confirmed the checks had been completed regularly, they told us, “The alarms are tested every week, and we have to complete online training.” And “The nurses are the fire marshals and people have their own fire evacuation plans in their care plans which are updated when there are any changes and reviewed monthly.” However, staff told us they had not completed a fire evacuation drill, “We haven’t done a mock fire evacuation yet, but I expect that will come with the new manager.”

The environment was not always safe for people. We observed not all the storage, equipment and linen rooms were locked including the sluice room which contained hazardous chemicals. We discussed our observations with the deputy manager, however, we checked the sluice room in the afternoon, and the door remained unlocked and wide open. There was building work being undertaken to add new bedrooms and an office on the first floor. However, there was only a sheet in place to stop people from entering this potentially hazardous area.

There were processes in place to maintain the environment. However, the day to day safety of the environment had not been monitored and action had not been taken to reduce potential risks. There were no effective systems in place to make sure staff understood and undertook their role in maintaining safety within the environment.

People told us there were enough staff on duty at the service. People told us, “Yes, there is enough staff. They do their best. They work hard. There is always one person in the lounge.” People told us they did not have to wait too long for assistance. Comments included, “Sometimes I wait longer than other times, it depends on the time of day, but it’s not unreasonably long.” Another person told us, “I don’t have to wait more than about 10 minutes.” One relative told us, “I believe so, I don’t know what the ratio should be, but I don’t see staff rushing around or alarm bells sounding ages. I just wish there were more female staff.”

Staff told us there was generally enough staff, though they could be rushed in the morning. Staff told us they had enough time to support people if they were distressed or wanted to chat. They described how they supported people to make choices and supported them to be as independent as possible.

We observed there were enough staff on duty to support people. Duty rotas were completed in advance and agency staff were used when needed. Staff checked on people in their rooms and call bells were responded to within a reasonable timeframe. We found some agency staff were not always effective in interacting with people. We observed on three occasions two different agency staff entering someone’s room; they scanned their devices and made a note of their visit but had no interaction or communication with the individual apart knocking on their door to alert them before entering. We raised this concern with the deputy manager, and they called the agency staff members immediately to address it.

Staff had been safely recruited and there were enough staff deployed to meet people’s needs and provide safe care. We examined several staff files, and all the required checks has been carried out and documents were all in date. In files we saw copied of references, photographic identification and Disclosure and Barring Service (DBS) completed checks. Nurses had personal identification numbers and were registered with the Nursing and Midwifery Council. Nursing staff had completed additional training to ensure they had the skills and knowledge to meet people’s nursing needs. The service used a dependency tool which helped the manager calculate the number of staff needed. The provider used the same employment agencies and agency workers as far as possible, for consistency. There were no records to confirm staff had received an induction or their competencies had been checked to make sure staff could support people safely.

People told us the home was kept clean. People told us that the staff always wore aprons and gloves when they were doing personal care and handling food. People's comments included, “Yes, the home is clean, very nice, and the cleaners are friendly and polite.” And “My bedding is changed regularly. There is nothing grubby around me, or I would say something.”

Staff told us they had sufficient equipment and personal protective equipment (PPE) to provide safe care. Staff had received infection prevention and control (IPC) training and were familiar with IPC processes to mitigate infection risks. Staff told us, “We do training in infection control. It’s important to keep people safe and well.” Also, “There is always enough PPE, we don’t run out.”

We observed that staff were using PPE effectively and safely. There were no restrictions to visitors; we observed visitors coming and going freely during the site visit. People’s bedrooms were clean and tidy, and people were well presented. The aroma throughout the service was pleasant. We observed staff using colour coded bags to separate laundry and waste. They explained the type of waste products that goes in each of the bags. The domestic told us they washed soiled or potentially contaminated clothes separately.

The provider had systems and processes in place to manage the risk of infection. The provider employed cleaning, laundry and housekeeping staff and there was a robust, daily cleaning schedule in place which included deep cleans for people’s rooms. The provider had plenty of PPE in place to keep people and staff safe. The kitchen area was clean and well managed. Infection control policy and procedure was available, audits had been completed to make sure the policy was being followed. There was system in place for waste disposal and managing soiled laundry to reduce the risk of contamination.

People told us they got their medicines on time. Staff comments included, “Yes, I get all my medicine on time, I don’t have to worry about that,” and “I get my medicines ok, and I know which ones are which and what they are for. They offer me paracetamol if I am in any pain.”

There were quality assurance measures in place for medicines. The deputy manager told us, “There is a medicine’s policy. Staff competencies are completed by the nurses when staff first start. The plan is to do this more regularly and roll out a 3-hour medicines refresher training for all staff face to face."

There was medicine management policy and procedure. There were protocols in place for individuals who had 'when required' medication. There were effective systems in place for order ordering, administering, recording and the disposal of medicines. Regular audits took place to identify errors and action was taken when errors were identified. The registered nurses were trained in medicine administration and management.