Archived: Pilgrim Homes - Evington Home

Updated 1 November 2017

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 15 August 2017 and was unannounced. The inspection team consisted of one inspector, an expert by experience and a specialist advisor. An expert-by-experience is a person who has personal experience of using or caring for someone who uses this type of care service. Their area of expertise was in older people living with dementia. The specialist advisor had experience working and caring for people within health care.

The inspector returned on the 16 August 2017, to complete the inspection.

Prior to our inspection we reviewed information we held about the service. This included the previous inspection reports, the provider’s action plan and notifications we had received. A notification is information about important events which the provider is required to send us by law. We received information from Leicester City Council and Leicester City Clinical Commissioning Group fund the care for some people who used the service. This information was used to plan our inspection.

We used a variety of methods to gain people’s views about the service. We spoke with eight people who used the service and three relatives. We made direct observations and also used the Short Observational Framework for Inspection (SOFI). A SOFI is where we observe care to help us understand the experience of people who were not able to have conversations with. We observed people being supported in the dining room at lunch time.

We spoke with two managers, two nurses and six members of care staff, a bank staff and the cook. We also looked at 17 people’s care records. We looked at recruitment files three care staff and nurse, and the staff training records. We looked at records relating to all aspects of the service including care, maintenance records for the premises and equipment, complaints and quality audits.

Updated 1 November 2017

This inspection took place on 15 August 2017and was unannounced. We returned on the 16 August 2017 to complete the inspection.

Pilgrim Homes – Evington Home is a care home that provides residential and nursing care for up to 30 people. The service specialises in caring for older people including those with physical disabilities, people living with dementia and those who require end of life care. Accommodation is over two floors. Bedrooms are all single rooms with an en-suite facility. At the time of our inspection visit there were 25 people in residency.

At our previous inspection in September 2016 we rated the service as requires improvement. We found the provider had made some improvements to how people’s medicines were managed and administered. Improvements were found to how risks to people’s physical health and wellbeing were managed and care provided was personalised. We also found some improvements had been made to the provider’s governance system used to monitor the quality of the service provided. Further action was needed to ensure those improvements were sustained. In addition the service did not have a registered manager in post. A registered manager is a person who has registered with us to manage the service and has the legal responsibility for meeting the legal requirements in the Health and Social Care Act 2008.

At this inspection we found the service remained requires improvement.

This service is required to have a registered manager. A registered manager was not in post. The provider had appointed two managers. We were aware that they had begun the process to become the registered managers for the service. Following our inspection visit they were confirmed as joint registered managers for Pilgrim Homes – Evington Home.

People told us there were not enough staff to meet their needs and to keep them safe and meant that their health and wellbeing had been put at risk or compromised. For example, people were not supported with their personal hygiene needs to then be able to attend the morning religious service which was important to them. A number of other examples were shared indicated that there was an institutionalised practices and regimes of supporting people. Staff acknowledged that there were delays at time but despite this people’s needs were met. Our observations during the inspection also supported the feedback we received.

The provider’s quality governance and assurance systems was not fully implemented. Audits we looked at were fragmented, lacked attention to detail and no plans to address the shortfalls found. Further action was needed to ensure any shortfalls identified were addressed in order to drive and sustain improvements.

People lived in an environment that was maintained. Further action was needed to ensure the premises and equipment were clean and that staff followed the infection control procedures.

Risks in relation to people’s care and support needs were assessed. People were involved in the development of care plans. That helped to ensure staff knew how people wished to be supported. Care plans were reviewed regularly. However, we found some inconsistencies in the records. The manager told us that the care plans were being transferred to an electronic care planning system. This process would enable care plans to be checked for accuracy and used to review people’s care to ensure any changes to care needs could be met.

People mostly received their medicines safely. People’s dietary and nutritional needs were mostly met. People had access to a range of healthcare services and attended routine health checks.

People’s safety was protected because staff were recruited through safe recruitment practices. We found there were sufficient numbers of staff to provide care and support when people needed it. Staff received an appropriate induction, training, supervision and appraisal.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. The policies and systems in the service supported this practice.

People’s privacy and dignity was respected. Staff’s approach was caring and they knew people well. People were involved in the review of their care plans which helped to ensure they received personalised care that was responsive to their needs. People maintained contact with family and friends. People’s religious needs were met. People’s wellbeing could be promoted through more l opportunities to engage in meaningful activities that were of interest to people.

People’s views about the service had been sought through a survey and at residents meetings. People and their relatives felt confident to raise concerns with the managers. A complaint process was available and advocacy support was made available to people.

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.