Archived: Pilgrim Homes - Shottermill House

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.

People also told us that they were happy with the environment that they lived in and the levels of cleanliness at the service. For example, one person told us, "As you can see my room is clean. Also if you put your dirty clothes in the box in the bathroom they come back to your room washed and ironed".

We also gathered evidence of people's experiences of the service by observing how people were supported by staff, looking at records and talking with five members of staff who were on duty and the manager. In the main, we found that people's care needs were being managed safely by the service and that staff had a good understanding of their roles and responsibilities in this area. When we spent time observing the interactions between staff and people who used the service we found this to be positive, friendly and caring.

We found that recruitment practices provided protection to people who lived at the service.

People told us that they were aware of the service's complaints procedure. As one person told us, "If I was unhappy I would try and speak to X (member of staff) first". A relative also confirmed they had been given information about how to complain when their family member moved into the service. We found that people's comments were listened to and in the majority of cases acted upon promptly.

People told us they were happy with the care and support they received.

One person said, "Staff treat me with respect and I have no concerns."

Another person said, "I get on well with the staff, meals are very good and I am treated well."

We also spent time observing the interactions between staff and people who use the service. We found this to be positive, friendly and caring.

We spoke with to staff who told us that they were very happy working in a home which has a good place to work. They felt supported in their work, had good training and felt the management was open and supportive.