Pelham Manor

Updated 19 January 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.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by one inspector.

Service and service type

Pelham Manor 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. Pelham Manor is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought and received feedback from the local authority. 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 all this information to plan our inspection.

During the inspection

We spoke with 2 people who used the service and 4 relatives. We spent time in the lounge, observing staff interactions with people and joined one person for lunch. We talked with 5 members of staff including the registered manager, senior carer and 3 care staff.

We reviewed a range of records. This included 2 people’s care records and medication records. We looked at 3 staff files in relation to recruitment. We also looked at staff training and staff supervision. A variety of records relating to the management of the service were reviewed including accidents and incidents and quality checks and audits.

Updated 19 January 2023

About the service

Pelham Manor is registered with the Care Quality Commission as a residential care home providing the regulated activity of personal care and accommodation for up to 7 adults with a learning disability and autistic people. At the time of the inspection there were seven people using the service. People had complex care needs, including learning disabilities, autism and physical health needs. Most people had limited verbal communication so were unable to provide feedback by speaking to us directly.

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

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

Right Support: People were not always supported to have maximum choice and control of their lives and it could not be assured staff supported them in the least restrictive way possible and in their best interests; staff did not always follow the policies and systems in the service to support best practice. Mental capacity assessments had not always been undertaken to assess if people had the capacity to make specific decisions. There was inconsistency in meeting the conditions of people’s Deprivation of Liberty Safeguards (DoLS) and DoLS had not been applied for in a timely manner to ensure any restrictions on people were lawful.

The service gave people care and support in a clean environment, but government guidance had not been followed to minimise the spread of any infection. There were plans to improve the furnishings and decoration. People were involved in personalising their rooms so these were decorated to their taste and contained things that were important to them.

Staff supported people to take part in activities and pursue their interests in their local area. They had access to day services provided specifically for autistic people. Staff communicated with people in ways that met their needs and planed for when they may experience periods of distress and anxiety.

Staff enabled people to access specialist health and social care support in the community. Staff supported people with their medicines in a way that achieved the best possible health outcome. Staff prepared food and drink to meet people’s dietary needs and requirements.

Right Care: Information about people’s care, treatment and support needs were not always easy to access to ensure peoples’ wellbeing was promoted. Although staff turnover had been high, people received kind and compassionate care from staff who understood and responded to people’s individual needs.

People were supported by staff who understood the wide range of strengths, impairments or sensitivities people autistic people may have. People who had individual ways of communicating, using body language, sounds, Makaton (a form of sign language) and pictures, could interact comfortably with staff and others involved in their care and support because staff had the necessary skills to understand them.

People and relatives were mostly positive about the quality of the service. People told us or indicated by the ‘thumbs up’ sign that staff gave the support they needed. Relatives commented that staff were caring, but there had been a high turnover of staff and managers that was not ideal for autistic people who liked routine.

There were enough staff to meet people’s needs and keep them safe. Staff understood how to protect people from poor care and abuse.

Right Culture: Quality assurance and monitoring systems were not always effective in identify shortfalls and improving the service for the people who used it. People and their family members were not involved in providing feedback about the service so their views could be acted upon.

People benefitted from the open and positive culture of the service where the management team was approachable and listened and responded to people’s views.

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 Requires Improvement (published 3 June 2019) and there was a breach of regulation. At this inspection we found additional breaches of regulation. The service remains rated requires improvement. This is the second time the service has been rated requires improvement.

Why we inspected

This inspection was prompted by a review of the information we held about this service. Also, in part due to concerns received about care planning, risk assessment and oversight of the service.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

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.

We have found evidence that the provider needs to make improvements. You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Pelham Manor on our website at www.cqc.org.uk.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.