Pilgrims Way Care Home with Nursing

At the time of the inspection 48 people were receiving a regulated activity. The inspection was carried out due to concerns about the management of the service. During the inspection we found 5 breaches of the regulations in relation to safe care and treatment, need for consent, person centred care, good governance and notifying CQC. The service was previously rated good but has now changed to inadequate.

We identified significant concerns about the service.

People were not well protected from the risk of abuse as incidents were not shared with the local authority when they needed to be. Action was not always taken following incidents to put in place mitigations and reduce the risk of re-occurrence. People’s medicines were not well managed. People’s care plans needed to be improved to ensure staff had the guidance they needed to support people. Staff did not have all the training they needed. People were not always well supported to manage risks to their health. We were not assured people’s rights were respected as the registered manager could not assure us people were always being deprived of their liberty lawfully. There was no system in place to ensure people had a deprivation of liberty safeguard in place (DOLs) if needed. Infection risks were not as considered and well managed as they needed to be.

People’s care needs were assessed using best practice tools. However, assessments were not then used to develop robust and holistic care plans. When decisions were made on people’s behalf the right steps were not always taken to ensure decisions were in people’s bests interests. Records were poor and care was not well monitored meaning action was not being taken to assure people’s care was being delivered in line with planned care. How people’s health was promoted could be improved and healthier snacks offered more often.

The management of the service needed to be improved. There were tensions in the staff team which at least one person living at the service was aware of and told us about. Governance had identified some concerns. However, there had been a lack of timely action and improving the service had not been sufficiently prioritised.

This service is being placed in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we user our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide. In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.