Pelsall Hall

Who the service is for

This service provides support to older people with physical disabilities and who may be living with dementia.

Key findings

We carried out this assessment on 2 September 2026. This service was previously rated as good. We carried out this assessment to confirm whether the rating of good remains accurate. This report does not provide detailed information on areas where we found practice continues to meet a good standard. Instead, our findings focus on any areas where the service needs to improve or where we found exceptional practice.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that staff and managers worked within the MCA. DoLS authorisations were appropriately applied for and overseen. People were not subject to unlawful or excessive restrictions, they had choice, control and freedom over their lives.

People had risks to their safety assessed and plans put in place to reduce the risks. Staff understood these and could describe how they supported people safely. Staff told us how they provided support to people to minimise risks relating to falls, pressure care, nutrition and hydration. Staff could recognise the signs of abuse, and we saw incidents were reported to the appropriate body. Where incidents and accidents had happened or things had changed there was analysis completed to look for learning. This led to changes to individual risk assessments and care plans and wider trend identification, which led to learning which was shared with staff. People were supported by enough suitably skilled staff. Staff told us they received an induction into their role and had regular updates to their training. We saw staff training was in place to support staff to meet people’s needs and this was updated regularly. People did not have to wait for their care and support, and staff were responsive to people’s needs. Staff understood how to administer medicines safely and could describe the support people needed as guidance was available to them. Medicines were stored safely and administered on time and recorded on medicine administration records.

Assessments and care plans were in place for everyone in an electronic system. These included guidance from other professionals where needed for staff on how to meet peoples assessed needs. A staff member told us, “The system is really good, the registered manager completes people’s assessments and care plans and then the seniors review and update them when things change or monthly.” Staff understood how to meet people’s needs and could describe how the evidence-based risk assessments and care planning tools were used to ensure people had effective support. People and their relatives were involved in regular reviews of care plans to ensure they were meeting individual outcomes. Where people could, they had consented to their care and we saw staff asked for consent when supporting people. Where people lacked capacity to consent, there were individual decision specific mental capacity assessments and best interest decisions in place.

Staff were observed supporting people to maintain their independence. We saw staff enabling people to maintain their own personal space, eat meals , have drinks and participate in activities. Staff described how they supported people to maintain their privacy, and we saw staff were kind and compassionate in their interactions with people. Staff offered choices to people and they were supported to decide how they spent their day, what meals and drinks they wanted and staff encouraged people to share their preferences.

Staff understood people’s individual preferences and could describe how care plans guided them to meet individual needs. This included information about people’s individual protected characteristics. Reviews were undertaken to assess people’s outcomes and ensure people received a positive outcome. A system was in place to investigate and respond to complaints. Where people or relatives made a complaint, a response was given within 28 days, and learning was shared with staff.

The provider delivered person-centred care to a high standard and respected people’s individual rights including protected characteristics. The provider sought to have an open culture where people felt safe and could share any concerns about their safety and well-being. Systems were in place to ensure the provider had oversight of the service and regular audits were carried out which led to a monitored action plan to oversee improvements.