We carried out a review of the data available to us about Pax Hill Residential Home EMF Unit on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Pax Hill Residential Home EMF Unit, you can give feedback on this service.
We found the following examples of good practice.
The home had set up a visiting pod in one of their ground floor bedrooms which had patio doors to the garden. The bedroom had been divided by a floor to ceiling Perspex screen and an intercom fitted. This enabled the visitor to enter the pod from outside the home and the person to enter the pod from inside the home thus preventing possible infection being brought in from outside.
Staff facilitated regular contact with people’s families. They had used technology to enable two people to celebrate their birthdays with their family members from all over the country. Staff had decorated the home's cinema and used the projector screen so people could chat to their family whilst being supported to open their presents.
The service had a bedroom on the top floor, at the end of a corridor, which they used for anyone newly admitted to self-isolate. There was a small lounge adjacent, with a view, which was for the person's sole use. This enabled them to access a larger, calm space, whilst self-isolating.
Staff had identified a space they could use with people living with dementia who could not understand the need to stay in their bedroom in the event of a COVID-19 outbreak. This would enable staff to support them to walk in one designated area.
The provider had supported staff well through the pandemic with the provision of bonuses to recognise their commitment and input. Staff’s uniforms were washed on-site to prevent the spread of infection. Staff had access to a shower and were provided with their meals by the provider. Staff had been supplied with meals from their cultural background where preferred, to suit their tastes.
Pax Hill Residential Home EMF Unit accommodates up to 26 people with dementia. At the time of our inspection, 15 people were living there. The building had been extensively renovated and areas had been newly built. The building had been thoughtfully furbished using published research into colours suitable for people with a dementia. There were three floors, which provided a mix of communal areas and individual bedrooms.
At our last inspection we rated the service requires improvement in safe and good in all other areas. This meant the service was rated Good overall. We asked the provider to take action to make improvements to staff recruitment and provide appropriate training where staff did not have a good command of English. We also undertook a focussed inspection on 15 June 2017 and found the provider was meeting legal requirements. At this inspection, we found the requirements around recruitment continued to be met. At this inspection we found the service to be Requires Improvement in Well-Led and Good in all other areas. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.
Why the service is rated Good.
Recruitment, staffing, medicine management, infection control and upkeep of the premises protected people from unsafe situations and harm.
Staff understood their responsibilities to protect people from abuse and discrimination. They knew to report any concerns and ensure action was taken. The registered manager worked appropriately with the local authority safeguarding adults team to protect people.
Staff were trained and supported to be skilled and efficient in their roles. They were very happy about the level of training and support they received and showed competence when supporting people.
The premises provided people with a variety of spaces for their use with relevant facilities to meet their needs. Bedrooms were very individual and age and gender appropriate.
Staff promoted people’s dignity and privacy. Staff provided person-centred support by listening to people and engaging them at every opportunity. Staff were very kind and caring and people using the service were calm.
Support plans were detailed and reviewed with the person when possible, staff who supported the person and family members. Staff looked to identify best practise and used this to people’s benefit. Staff worked with and took advice from health care professionals. People’s health care needs were met.
People had a variety of internal activities (such as music therapy) and external activities which they enjoyed on a regular basis.
Relatives’ views were sought, and opportunities taken to improve the service. Staff were supervised, supported and clear what was expected of them.
Audits and checks were carried out in-house, but had not identified the shortfalls we found. Staff needed training about restraint. Although staff knew people well, people did not have clearly written Personal Emergency Evacuation Plans and staff had not taken part in emergency evacuations. We also found the registered manager had informed Public Health England about a suspected outbreak of Norovirus but did not notify the Care Quality Commission. The registered manager took immediate action to address these shortfalls.
People’s legal rights were understood and upheld. People were supported to have maximum choice and control of their lives; the ethos of the home supported this practice.
Further information is in the detailed findings below.
After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breach. We undertook a focused inspection on the 15 June 2017 to check that they had followed their action plan and to confirm that they now met legal requirements.
This report only covers our findings in relation to this legal requirement. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘Pax Hill Residential Home EMF Unit ‘on our website at www.cqc.org.uk.
Pax Hill Residential Home EMF Unit is registered to provide residential care for up to 26 older people who experience dementia. At the time of the inspection there were 16 people living at the service.
The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
At our focused inspection on the 15 June 2017, we found that the provider had followed their action plan which they had told us would be completed by the 02 May 2016 and legal requirements had been met.
The provider had taken action to ensure that existing staff recruitment files were complete and that the correct information was requested from any new applicants to ensure people’s safety. The registered manager had identified those staff who required support to further develop their English language skills and this was being provided. It will take further time for these changes to become embedded within the service.
The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
The provider had completed relevant recruitment checks in relation to staff. However, they had not always ensured that applicants had provided a full employment history or a satisfactory written explanation for any gaps in their employment. Therefore, there was the potential that people might have been placed at risk from the recruitment of unsuitable staff as the provider had not fully assured themselves of their suitability for their role. The provider had not ensured that they had assessed the adequacy of staff’s English language skills. Therefore it could not be established whether staff possessed the required level of competency to be able to communicate effectively with people who experienced dementia.
People and their relatives told us there were enough staff to meet people’s needs. People’s level of dependency was assessed monthly and this information was used to determine the required level of staffing to ensure people’s needs were met safely.
People were safeguarded as staff understood their roles and responsibilities. They had undergone relevant training and had access to written guidance to ensure people’s safety.
People’s relatives told us risks to their loved ones were well managed. Risks to people had been screened, assessed and action was taken by staff to ensure identified risks were managed safely.
Staff who administered people’s medicines had undergone appropriate training. There were processes in place for the safe ordering and disposal of medicines. A staff member was observed not to lock the medicines trolley when administering medicines to people. Although the trolley was always within their sight, there was a potential risk that unauthorised people could have accessed the trolley. This was brought to the attention of the deputy manager who took action to address this with the staff member.
Staff received an induction to their role, training and supervision of their work. The registered manager and the deputy manager had undertaken training in dementia leadership. This enabled them to develop staffs’ practice and improve people’s experience within the service. People received their care from staff who received appropriate support to carry out their role.
Staff had undertaken training on the Mental Capacity Act 2005 and understood the principles of the Act. All of the people accommodated had been assessed as lacking the capacity to consent to their care and treatment at the service. A Deprivation of Liberty Safeguards application had been submitted for each person accommodated as per legal requirements.
People told us they were happy with the food provided and were observed to enjoy their meals. People were offered a variety of nutritious foods and drink across the day which met their dietary needs and preferences.
Staff arranged for people to be seen by a variety of health care professionals as required to maintain their physical and mental health.
People told us staff treated them well. One person told us ”Staff are kind, they treat us properly.” Staff were observed to communicate well with people, using their voice, touch and positioning to facilitate positive communications with people.
People told us staff involved them in making decisions about their care. Staff had access to relevant information about what areas of decision making people were able to participate in and how to support them to make decisions.
People’s privacy and dignity were promoted by staff throughout the course of the inspection. Staff spoke with people politely and with respect. .
People’s families were observed to be able to visit freely. People’s families were encouraged to attend social activities that staff arranged and to celebrate events with their loved ones.
Staff had received relevant training to enable them to support people with their end of life care. People had appropriate care plans to ensure they received the quality care they required.
People’s relatives told us their loved ones needs had been assessed and that they were involved in care planning and reviews of their care. If people experienced behaviours which could challenge staff, then there was written guidance for staff which they were aware of and understood. People’s care was responsive to their needs.
Staff used the information gathered during the care planning process to plan individualised social care for people, which reflected their past occupation and interests. Staff recognised that people needed to be engaged in purposeful activity that had an outcome and meaning for them. Activities reflected the time of year and the seasons to support people to be orientated to the time of year and to stimulate their memory of celebrations and events.
People and their relatives were provided with a copy of the complaints process. Although no written complaints had been received, a person’s relative told us any minor issues they raised verbally were resolved promptly. People’s complaints were listened and responded to.
People appeared to be happy, content and well cared for by staff. Staff were observed to follow the provider’s philosophy of care when meeting people’s needs. There was an open culture, staff’s views were sought and they felt listened to. This enabled staff to feel they could raise issues if they needed to in order to ensure people received good quality care.
People, their relatives and staff told us the service was well managed. The deputy manager was frequently on the floor supporting people and staff. People, their relatives and staff told us the registered manager and the deputy were readily accessible to speak with if they wished.
There were processes in place to enable the registered manager to audit the service for the purpose of identifying any areas for improvement for people. Records demonstrated that when areas for improvement had been identified these had been addressed for people.
People’s relatives told us they had been asked to complete surveys about the quality of the service provided, the results of which were very positive and did not highlight any areas for improvement.
We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of the report.
We found that staff had sought the consent of people or their representatives to provide their care.
People had care plans and risk assessments in place that identified their care needs and provided staff with guidance about how to meet them. We found that staff were knowledgeable about people's care needs.
Medicines were administered safely and stored appropriately.
Relevant pre-employment checks had taken place in relation to staff employed to provide the service.
There was a complaints system in place and people had been provided with details of how to make a complaint.