Innovations Wiltshire Limited – Pelham Court is a small domiciliary care agency rated Good overall following a KLOE inspection in June–July 2022, with only Safe and Well-Led assessed. No failure themes were identified; the service demonstrated strong safeguarding, personalised care planning, medicines management, and an open, person-centred culture under a well-regarded registered manager.
Strengths
· People felt safe and expressed high trust in staff, with no missed visits reported.
· Personalised positive behaviour support plans co-created with external professionals, reviewed regularly.
· Medicines administered as prescribed with no MAR gaps; annual competency checks completed.
· Sufficient PPE supply maintained throughout COVID-19; infection control policy updated.
· Accidents and incidents analysed for trends; follow-up actions taken to prevent reoccurrence.
Quality-Statement breakdown (10)
safe: Systems and processes to safeguard people from the risk of abuse
Good
safe: Assessing risk, safety monitoring and managementGood
safe: Staffing and recruitmentGood
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: Managers and staff being clear about their roles, understanding quality performance, risks and regulatory requirements; Continuous learning and improving careGood
well-led: Engaging and involving people using the service, the public and staff, fully considering their equality characteristicsGood
Innovations Wiltshire Limited – Pelham Court is a domiciliary care agency rated Requires Improvement overall at its first rated inspection, with medicines management and person-centred care planning identified as the primary areas requiring action. The service demonstrated strengths in caring, effective practice, and well-led governance, with staff consistently praised by people and relatives.
Concerns (6)
criticalMedication management: “Medicines administration records had limited information about the medicines, for example no dosage, route or times to be taken which could result in people not receiving their medicines as prescribed.”
moderateCare planning: “Care plans were not always person centred but more task orientated... There were no details of how the person preferred to have their care done or if they preferred a male or female carer.”
moderateRecord keeping: “We found the service did not have all the details of where a person had a LPA and this was not consistently recorded in people's care records.”
moderateRecord keeping: “For some people there had been incidents, such as choking or falling where associated risk assessments had not been completed.”
minorCommunication with families: “People and their relatives told us they weren't always informed when a carer was running late. One person said 'No, they don't often let me know if they are late'.”
minorPerson-centred care: “Care plans did not include information on people's specific wishes, preferences, likes or dislikes around aspects of their life other than personal care.”
Strengths
· People and relatives were consistently complimentary about staff, describing them as delightful, caring, and thorough.
· Staff had good knowledge of safeguarding and demonstrated confidence to identify and act on concerns.
· Effective recruitment practices including DBS checks and reference checks ensured staff suitability.
· Staff received thorough induction, regular supervision, and relevant training including dementia and first aid.
· Good understanding of Mental Capacity Act principles demonstrated by staff with appropriate consent practices.
Innovations Wiltshire Limited - Pelham Court was rated Good overall following a July 2018 announced inspection, with four of five key questions rated Good and Well-led rated Requires Improvement. A single regulatory breach was identified under Regulation 18 of the Registration Regulations 2009 for failure to notify CQC of significant events, alongside minor medicines recording and protocol gaps, though all other aspects of care were found to be safe, effective, caring and responsive.
Concerns (4)
criticalGovernance: “The registered manager did not notify the CQC of important events, such as when the Police was contacted or a Deprivation of liberty safeguard had been authorised.”
moderateMedication management: “We saw there had been four medicines administration and nine recording errors in the past 12 months.”
moderateMedication management: “PRN medicines, protocols were in place. However these did not contain all the information needed, such as what the medicines were for, when the person might need it and the maximum dose.”
moderateRecord keeping: “We found where people were receiving support with their medicines, risk assessments were not in place.”
Strengths
· People felt safe and spoke positively about staff, describing them as kind, caring, respectful and friendly.
· Sufficient staff were deployed effectively with continuity of carers provided where possible, including paid travel time to avoid rushing.
· Personalised, detailed care plans were developed with involvement from people and their relatives, including 'pen pictures' and daily routine information.
· Staff received thorough induction, regular supervisions, annual appraisals and relevant training including safeguarding and MCA.
· Registered manager was proactive in reducing social isolation, supporting community access and implementing 'Making each day count' wellbeing initiative.
This focused KLOE inspection found that Innovations Wiltshire Limited – Pelham Court had remedied the previous breach of Regulation 18 by implementing systems to ensure timely statutory notifications. The Well-led domain was rated Good, with no other key questions inspected at this visit.
Concerns (2)
criticalIncident learning: “the service had not notified us of incidents they were legally required to. This was a breach of Regulation 18 of the Care Quality Commission (Registration) Regulations 2009.”
moderateMedication management: “there had been a medicine's incident at the service...the registered manager stopped staff administering medicines until they were re-trained.”
Strengths
· Notifications now submitted appropriately and without delay following previous breach, with systems put in place to ensure compliance.
· Monthly team meetings and 'best practice' meetings held to share information, good practice and facilitate staff learning.
· People's feedback sought via surveys, results analysed, and responsive action taken, including changing care workers at a person's request.
· Following incidents, action taken to prevent reoccurrence, including retraining and interim management cover for medicines administration.
· Quality monitoring systems under review to increase staff involvement and improve engagement.
Quality-Statement breakdown (4)
well-led: Notifications submitted as required under Regulation 18 of the CQC (Registration) Regulations 2009.Good
well-led: Monthly team meetings and best practice sessions used to share information and facilitate learning.Good
well-led: Feedback from people sought, analysed and used to drive service improvements.Good
well-led: Quality monitoring systems in place and under review to increase staff participation.Good
caring: Dignity and respect
Good
caring: Promoting independenceGood
caring: People's views and involvementGood
responsive: Person-centred care planningRequires improvement
responsive: Complaints handlingGood
responsive: Flexibility and responsiveness to needsGood
well-led: Governance and quality assuranceGood
well-led: Leadership and staff supportGood
well-led: Community engagement and partnershipGood
caring: Emotional wellbeing and person-centred approach
Good
responsive: Person-centred care planningGood
responsive: Complaints handlingGood
responsive: End of life careGood
well-led: CQC notifications and regulatory complianceRequires improvement
well-led: Quality assurance and governance systemsGood
well-led: Staff support and leadership cultureGood