Background to this inspection
Updated
15 July 2016
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 13 May 2016 and was unannounced. The inspection team consisted of two inspectors and an expert by experience. An expert-by-experience is a person who has personal experience of using or caring for someone who uses this type of care service.
Prior to the inspection we reviewed all the information we had about the service.
This included information sent to us by the provider about the staff and the people who used the service. We reviewed the Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. We looked at notifications that had been sent to us by the provider. A notification is information about important events which the provider is required to tell us about by law.
During our inspection we spoke with the registered manager, six people that used the service, three relatives, one visitor and five members of staff. We looked at five care plans, three recruitment files for staff, medicine administration records, supervision records for staff, and mental capacity assessments for people who used the service. We looked at records that related to the management of the service. This included minutes of staff meetings and audits of the service. We observed care being provided throughout the day including during a meal time.
The last inspection took place on the 25 February 2014 where no concerns were identified.
Updated
15 July 2016
The inspection took place on the 13 May 2016 and was unannounced.
Pilgrim Homes - Shottermill House is a residential care home that can accommodate up to 31 people. The service provides care and support to older people who have a Christian belief. At the time of the inspection there were 30 people living at the service.
On the day of the inspection there was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
Risk assessments for people were not always detailed or informative and did not always have measures in place to reduce the risk of harm. Accidents and incidents were not always recorded in detail and trends were not always analysed.
People’s human rights were not protected because the requirements of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty (DoLS) had not been followed. Evidence of mental capacity assessments specific to particular decisions that needed to be made were lacking.
Systems were not in place to monitor and improve the quality of the service that people received. This included audits, surveys and meetings with people and staff. The provider had on occasions failed to inform the commission of important events such as people falling and injuring themselves.
Staff had not always received all the appropriate training for their role. We have made recommendations around this. However, their competencies were regularly assessed through supervisions.
People did not always have the choice of nutritious food that they should expect. We have made recommendations around this.
People had access to a range of health care professionals, such as the GP, dietician and chiropodist.
There were times when staff were not as kind as they could have been. However people and relatives told us that staff were caring and felt involved in the planning of their care.
We saw that care plans had detail around people’s backgrounds and personal history. Staff knew and understood what was important to the person.
Care plans for people were not always reviewed or reflective of people’s up to date needs. There was a risk that staff did not have the most appropriate information to enable them to respond to people effectively.
People, relatives and staff told us that there needed to be more activities both inside and outside of the service.
People’s needs were met because there were enough staff at the service. We saw that people were supported in a timely way with their care needs.
Staff had knowledge of safeguarding adult’s procedures and what to do if they suspected any type of abuse. Staff had undergone recruitment checks before they started work. People’s medicines were administered and stored safely.
In the event of an emergency, such as the building being flooded or a fire, there was a service contingency plan which detailed what staff needed to do to protect people and make them safe.
People and relatives said if they needed to make a complaint they would know how to. There was a complaints procedure in place for people to access if they needed to.
People, relatives and staff said that the service was well managed.
Staff said that they felt supported. One member of staff said that that they felt supported by the registered manager who they could go to them if needed.
During the inspection we found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and a breach of the Care Quality Commission (Registration) Regulations 2009. You can see what action we told the provider to take at the back of the full version of the report.