Pilgrims Way Care Home with Nursing

Updated 6 December 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

Inspection team

The inspection team consisted of 3 inspectors and 2 Experts 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.

Service and service type

Pilgrims Way Care Home with Nursing is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Pilgrims Way Care Home with Nursing is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations. At the time of our inspection there was a registered manager in post.

Notice of inspection

The inspection was unannounced.

What we did before the inspection

We reviewed information we received about the service since the last inspection. This included details about incidents the provider must notify us about, such as serious injuries and safeguarding concerns. We sought feedback from the local authority who did not have any serious concerns about the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used information gathered as part of monitoring activity that took place on 21/08/2023 to help plan the inspection and inform our judgements.

During the inspection

We spoke with 10 people who lived in the service and 10 relatives about their experience of the care provided. We observed multiple interactions between people and staff throughout the day. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. We spoke with 10 people who work in the service including the registered manager, nurses and care workers, kitchen, housekeeping and reception staff. We reviewed a range of records including 5 peoples’ care records and multiple medication records. A variety of records relating to the management of the service were reviewed including recruitment records, health and safety checks, meeting notes, training records and audits.

Updated 6 December 2023

About the service

Pilgrims Way Care Home with Nursing (Pilgrims Way) is a residential care home providing nursing and personal care for up to 76 people. Since the service was registered there has been some reconfiguration of the space and as a result the service can accommodate 58 people. People's needs were varied and included people with high level nursing needs and some requiring to be cared for in bed. The service was arranged on two levels with an adjacent building called the Coach House linked via a covered walkway. At the time of our inspection there were 48 people using the service.

People’s experience of using this service and what we found

A new registered manager had been appointed since our last inspection and they had implemented some quality assurance processes, but these were not yet fully embedded within the culture of the service. Some elements of medicine management were not always safe.

People told us they felt safe living in Pilgrims Way. One person said, “I feel safe because the building is secure, there is always someone around and I am in the right place for the care I need.” Another person told us “I feel safe here, I don’t worry about anything. I was living at home, but I needed more help.” Relatives agreed that their loved ones were safe and happy.

People had comprehensive risk assessments and received care and treatment from staff who knew them well. There were enough staff with the right skills and training to meet people’s needs. Infection control was managed safely, and lessons were learned when things went wrong.

Most people told us the food was good and people’s dietary needs and preferences were met. People told us they had enough to eat and were given choices each day. Care staff and kitchen staff knew about any special diets and textures.

Recruitment was managed safely and there were enough staff deployed to provide safe care for people. Staff told us the registered manager was approachable and supportive.

People were involved in decisions about their care where possible and they received care which promoted their dignity and privacy. Some people attended activities they enjoyed when they could.

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

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good, published 13 December 2018.

Why we inspected

This inspection was prompted by a review of the information we held about this service and the length of time since the last inspection. As a result, we undertook a comprehensive inspection to review the five key questions of safe, effective, caring, responsive and well led.

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.

The overall rating for the service remains good.

Follow Up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.