Pelham House

⚠ Temperatures of medicines in cold storage were not being monitored, and the thermometer used for this had broken and not been replaced, meaning staff could not be fully assured these medicines were safe to use.

⚠ The temperature of the dedicated room where all other medicines were stored was not monitored, meaning staff could not be fully assured these medicines were being stored at an appropriate temperature.

⚠ On three people’s records, staff had not appropriately documented on individual risk assessments how risks to them from malnutrition would be managed, despite arrangements being in place to monitor them.

⚠ Systems in place to assess and monitor the quality of the service were not effective, as action was not always taken to remedy issues in a timely manner. Concerns about the quality of people’s care records, specifically the updating into the provider’s new format, were not dealt with promptly due …

⚠ Audits of people’s care records had not been effective, as they had not identified that staff were not properly completing people’s individual nutritional risk assessments.

⚠ The registered manager had not reported three expected deaths this year at the home, including two deaths that occurred in the week prior to the inspection, which they are required to do.