Pilgrim Wood Residential Home

Updated 5 October 2021

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 Care Act 2014.

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

Pilgrim Wood Residential Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The service had a manager registered with the Care Quality Commission. 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.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We received feedback from five people who lived at the home and three relatives as part of our monitoring activity of the service. We reviewed information we had received about the service since the last inspection, including notifications and safeguarding records. The provider sent us documentation including audits, training records, reports of quality monitoring visits and the minutes of meetings. The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report. We used all of this information to plan our inspection.

During the inspection

We spoke with four people who used the service about their experience of the care provided. We spoke with seven staff, including the registered provider, the registered manager, a deputy manager, three care staff and the chef. We observed the support people received and the engagement they had with staff. 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 reviewed records including risk assessments and support plans for three people. We checked accident and incident records and the arrangements for managing medicines.

After the inspection

The provider sent us further information which demonstrated safe recruitment procedures had been followed when employing staff. We spoke with a healthcare professional who had regular contact with the home.

Updated 5 October 2021

About the service

Pilgrim Wood Residential Home is a care home without nursing for up to 35 older people, including people living with dementia. There were 24 people living at the home at the time of our inspection.

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

People felt safe at the home and when staff provided their care. People said staff were always available when they needed them and knew how they preferred their care to be provided.

People received consistent care from a stable staff team who knew their needs well. Staff retention at the home was good and staff supported one another well to ensure people received the care they needed. The staff team had demonstrated admirable commitment during the coronavirus pandemic. Many of the team had moved into the home to minimise the risk of the virus entering the service.

Staff received safeguarding training and knew how to report any concerns they had about people’s safety or wellbeing. The provider’s recruitment procedures helped ensure only suitable staff were employed.

Standards of fire safety had been improved since our last inspection. When accidents or incidents happened, these were reviewed to identify any actions that could be taken to reduce the risk of harm to people. Medicines were managed safely. Staff maintained appropriate standards of infection prevention and control.

The quality of documentation had improved since our last inspection. This included people’s care plans, which were person-centred and contained detailed information for staff about how people’s care should be provided.

People were involved in decisions that affected them and staff encouraged people to make choices about their day-to-day lives. People who lived at the home and their relatives had opportunities to give their views at regular meetings.

The registered manager and provider had improved the governance and management oversight of the service. Two deputy managers had recently been recruited to strengthen the home’s management team.

Staff received good support to do their jobs and felt valued for the work they did. Staff said the registered manager and the provider were supportive and cared about their welfare. Team meetings took place regularly and staff were encouraged to speak up if they had ideas or concerns.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 12 December 2019) and there were two breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 10 October 2019. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment and good governance.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from Requires Improvement to Good. This is based on the findings at this inspection.

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

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.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.