Archived: Pennsylvania House

We carried out this comprehensive inspection in October 2016 to check whether the above issues had been addressed and whether people using the service were safe and receiving effective, caring and responsive care in a well led service. There were 16 people living at Pennsylvania House at the time of this inspection with one person in hospital and one person receiving short term respite care. The home has remained under whole home safeguarding since February 2016 which means it is being monitored by the local authority safeguarding team. An admissions suspension was placed on the home to prevent the service admitting any new admissions and remains in place. As a protective measure community matrons and safeguarding nurses continued to regularly visit the home to ensure people’s needs were being met. We continued to receive concerns arising from these visits, where although the home reacted well to the concerns when told, they did not identify them or put sustainable or safe systems in place to manage the home safely. Concerns included the lack of management of the service, safe medication administration, safe moving and handling, safe staffing levels and supervision of people living at the home and training.

At this inspection we found no improvements had been made other than we received an action plan following the inspection in February 2016 and environmental health visited the home on 18 March 2016 giving a Food Rating of 5, so the cleanliness of the kitchen had improved. There were continuing breaches in relation to the safe care and treatment of people and further breaches in relation to safe staffing levels, application of the Mental Capacity Act 2005, cleanliness and infection control, management of risk, maintenance and meeting people’s individual needs.

We continued this inspection for three days due to our concerns and contacted environmental health and the fire safety officer to share our concerns as well as the safeguarding team. For example, a known bed bug infestation had not been well managed by staff who had no clear instructions about what to do. We asked the provider to deal with this issue immediately. As the fire alarm testing records showed no tests for one month and the general maintenance and cleanliness of the building was shabby we asked the fire safety officer to visit with us on the third day. They also found continued evidence of poor fire safety management despite making recommendations in January 2016. They will be issuing an enforcement notice using their own processes. We spoke to three health professionals visiting the home daily as part of the protection plan arising from the safeguarding meeting discussions. They continued to pick up issues with the correct use of pressure relieving equipment, management of bed bugs and general management. They all said the home and staff appeared unprofessional and shabby, although staff were friendly and helpful, they did not look smart and no staff wore name badges. Staff said they had asked the provider for uniforms and name badges many times.

We found nine breaches relating to seven Regulations of the Health and Social Care Act 2008 (Regulated Activities) 2014. The overall rating for this service following this inspection in October 2016 is Inadequate which means it will be placed into special measures. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration. For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures. We asked the provider to voluntarily agree not to admit further admissions until further notice. The provider agreed to this.CQC is now considering the appropriate regulatory response to resolve the problems we found.

Pennsylvania House is registered to provide accommodation with personal care for up to 25 adults. It offers a service for people who may have dementia, mental health needs or learning disabilities. There was a registered manager in post. 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. However, the registered manager had moved to the provider’s second service and was based there. The provider assured us the two deputy managers at Pennsylvania House supported by the registered manager would be able to safely manage the home. We found this not to be the case, they were not listened to or empowered to make decisions to ensure consistent management.

Risks to people were not always minimised through the effective use of risk assessments. Staff did not follow care plans but relied on verbal information from each other and poor, basic handovers between shifts. There were insufficient suitably trained staff deployed to keep people safe and meet people's care needs in a timely manner. Staff did not always have the knowledge and skills required to meet people's individual care and support. Although they had training in a range of topics, this was not used to deliver care, staff competency was not managed and staff were not regularly supervised to ensure they were able to meet people’s needs. The provider had good recruitment and vetting procedures but staff did not always have the induction, training and supervision they needed.

People did not receive care that was personalised and reflected their individual needs and preferences. Staff did not have the time to deliver personalised care or use information in the care plans to ensure they knew how to meet individual needs. Although activities were organised by the activity co-ordinator their knowledge of people’s needs was random, they did not use the care plans or relate people’s preferences to activities. They told us they did not feel equipped to manage people with dementia and were restricted by a lack of staff. Staff had little input in managing engagement and stimulation. Although the activity co-ordinator delivered some meaningful activities and one to one sessions with some people they recorded events by activity. This meant some people with more complex needs spent long periods unstimulated and inactive.

People’s rights were not protected. Although applications had been made following legislation to prevent people leaving the home for their own safety, the principles of the Mental Capacity Act 2005 were not followed to ensure that people were consenting or being supported to consent to their care and support.

People's medicines were administered and recorded and staff knew what to do but lack of time did not ensure people were taking their medicines safely.

People's right to privacy and dignity was compromised due to lack of staff time and response. Most people were unkempt, wearing soiled clothes and staff were unable to effectively manage people’s continence.

Systems in place to monitor the quality of the service were ineffective. The management systems were insufficient to provide leadership and guidance to the care staff. People were at risk of receiving poor, undignified, inconsistent and unsafe care. Little improvements had been made since the last inspection, despite the concerns being known to the provider for some time.

The last inspection of the home was carried out on 8 an 17 February 2015. No concerns were identified with the care being provided to people at that inspection.

Pennsylvania House is registered to provide accommodation with personal care for up to 25 adults. It offers a service for people who may have dementia, mental health needs or learning disabilities.

There was a registered manager in post. 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.

This report only covers our findings in relation to the concerns we received. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Pennsylvania House on our website at www.cqc.org.uk.

People were not protected from the risks associated with the control and spread of infection. The vanity units surrounding a sink in two bedrooms were in a poor state of repair, a toilet seat was badly cracked and there were areas in the kitchen which were not covered with an impermeable floor covering. The paper towel and liquid soap dispensers in the kitchen hand wash sink were empty which meant staff could not maintain good hand hygiene.

The standard of cleanliness in people’s bedrooms and communal areas was good. However; the standard of cleanliness in the home’s kitchen was of an unacceptable standard.

There were sufficient staff available to meet the needs of people during the day however; staffing levels at night were not in accordance with people’s assessed needs. For example, it was stated in some people’s care plans that they required the assistance of two staff to change position and to support them to use the toilet every two hours. Staff told us there were seven people who required the assistance of two staff. Nights were covered by one waking and one sleep-in carer and records seen showed that people had been supported by only one member of staff.

Following a visit from the local authority safeguarding team the registered manager had taken action to request an assessment from a speech and language therapist for one person identified as being at risk of choking. However; a risk assessment and plan to manage the risk had not been completed. Although the staff we spoke with were aware of the risks to the person and knew they required supervision, this could potentially place the person at risk of receiving unsafe or inappropriate care from staff who did not know the person well such as agency staff which were used by the home.

Staff had received training about how to recognise and report abuse. They told us they would not hesitate in raising concerns and they were confident action would be taken to help keep people safe.

People looked relaxed and comfortable with the staff who supported them. Staff interactions were kind and respectful and they responded quickly to any requests from the people who lived at the home. People felt safe and well cared for. One person said “It’s very good here and the staff are all very nice.” Another person said “I am very well looked after. I feel very safe here and I get what I need. I had a new mattress yesterday which is very comfortable.” A visitor told us “Things are improving and the staff seem very nice. I have never seen anything concerning.”

Equipment used to assist people with their moving and handling needs had been regularly serviced to make sure it remained safe and fit for purpose. Regular checks were carried out on the home’s fire alarm, emergency lighting and fire detection systems and staff had received up to date training in fire safety. Personal emergency evacuation plans (PEEPS) had not been completed for each person who lived at the home. This information would assist staff and emergency services if people needed to be evacuated from the premises. We discussed this with the provider and registered manager who informed us they were in the process of completing a PEEP for each person following recommendations from a fire safety officer.

We found the service to be in breach of three of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

On the day of our visit we were told there were 24 people living at Pennsylvania House. We spoke with five people living at the home, two relatives, eight members of staff, which included the registered manager and a visiting healthcare professional. We spent time observing how people's care and welfare needs were met and looked at three people's care files and medicine records in detail.

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

Is the service safe?

People's individual risks were identified and the relevant risk assessments were conducted. This meant that when staff were accessing information about a person's needs through their risk assessments, they would be able to determine how best to support them in a safe and therapeutic way.

Medicines were safely administered. We saw the medicine recording records had been appropriately signed by staff when administering a person's medicine. We looked at the blister packs, boxes and bottles where medicines were stored. We saw that they had been administered and the corresponding records had been signed. This showed that when looking at records in line with people's needs there was an accurate audit trail for staff to refer to.

Is the service effective?

The service was effective because people were spending their time relaxing in the lounge and in their bedrooms. People did not appear rushed and the home was relaxed and homely. Comments included: 'Pennsylvania House is a lovely place. The staff are lovely. I have no concerns. Best place for my Dad. If I need to talk, I will speak to the manager, she is lovely. They (the staff) keep me up to date and organise doctor's appointments when needed'; 'I like living here, the staff are nice'; 'X (relative) loves it here' and 'I have no concerns about Pennsylvania House and this is a good placement for X.' During our visit, we saw that people appeared relaxed and contented.

Care plans were up-to-date and were written with clear instructions. They were broken down into separate sections, making it easier to find relevant information, for example, health needs, personal care, mobility, anxiety management and eating and drinking. We saw evidence of health and social care professional visits and appointments, for example GP, district nurse and occupational therapist. These records demonstrated how other health and social care professionals had been involved in people's care to encourage health promotion and ensure the timely follow up of care and treatment needs.

Is the service caring?

The service was caring because staff were observant to people's changing moods and responded appropriately. Staff communicated appropriately with people, and we saw the relationships between staff and people in the home were positive. Throughout our visit we saw people were appropriately dressed and cared for to promote their dignity. For example, people were dressed smartly and their hair was brushed as they liked. Staff offered care which was both kind and compassionate in order for people to experience a general sense of wellbeing.

Is the service responsive?

Care files gave detailed information about people's health and social care needs. They included personal information and identified the relevant people involved in their care. The care files were presented in an orderly and easy to follow format, which staff could refer to when providing care and support to ensure it was appropriate. Relevant assessments were completed and up-to-date, from initial planning through to on-going reviews of care.

Below is a summary of what we found. The summary is based on information gathered during conversations with people who used the service, relatives, staff and management of Pennsylvania House.

Is the service safe? We found that Pennsylvania House had systems in place to ensure people were protected against the risk of abuse. Staff were aware of the signs and symptoms of abuse and how to report any allegations.

The Mental Capacity Act and Deprivation of Liberty Safeguards policy outlined how staff were to ensure the person's best interest were to be considered at all times and how to seek guidance.

We observed poor manual handling practices which could have put the person and/or the staff at risk of injury.

Is the service effective? All of the people we spoke with and interacted with who received care from Pennsylvania House were happy with the quality of care they received. People told us 'I am happy here'.

The care plans reflected the current medical and psychological needs of the people living in the home. However they did not contain information on people's preferences, these included, what time they would like to go to be and their food likes and dislikes.This meant staff were unaware of the person's choices and wishes.

Is the service caring? People told us they were well cared for by staff. Their comments included 'they are nice here'. We heard staff talk with the people who lived at Pennsylvania House in a caring manner.

Is the service responsive? The service was responsive, we found people were aware of the complaints procedure but had not raised a complaint as they were happy with service they received. People told us 'I've never needed to make a complaint. They are very good'.

The provider's complaints policy also included procedures for resolving and recording minor issues raised by people who used the service. We saw these issues had been effectively investigated and resolved.

Is the service well led? The service did not have adequate quality assurance systems in place. We saw that audits of the environment and experiences of people who lived at the home had been completed. However we saw poor practices relating to the care and well fare of people and the management of medication storage and administration.

The premises did not ensure people were cared for in a safe and clean environment.

Staff told us they felt supported by the management team. One person said the home was "Well run".

To help us understand the experiences of people we used our SOFI (Short Observational Framework for Inspection). This tool allows us to spent time watching what is going on in a service and helps us record how people spend their time, the type of support they get and whether they have positive experiences.

The people we spoke with and their visitors were complimentary about the home and about how they were involved in deciding about their care and support. We saw how people's care and welfare was provided with dignity and respect in line with their care plan. One person told us 'They look after me very well, I like it here'. We spoke with three visiting professionals who also spoke highly of the home. One professional said; 'I've no concerns about the care of people here. There's always enough staff around to help and they always contact me if there are concerns about someone.'

The home was undergoing some improvements to decoration following a burst pipe. People's bedrooms were cleaned regularly and all people we spoke with told us their rooms were clean and were as they liked their room to be. All other areas of the home were cleaned daily and as required. Two visitors we spoke with told us, 'The cleanliness is fine here, we've no complaints.'

There were 22 people living at the home when we visited. We spoke with 15 people, a relative and a visiting therapist about people's experiences of living at the home. We looked in detail at three people's care records. One person said 'I am happy here, I wouldn't go anywhere else'. A relative said 'It couldn't be better, staff are absolutely wonderful, and x is eating better'.

We found people were offered choices about their day to day preferences and staff respected their decisions. We observed that people were treated with warmth, dignity and respect by staff that interacted well with people. However, at times, some people seemed withdrawn when there wasn't much going on for them.

We spoke with nine staff including the registered manager, a senior member of staff, and eight care staff. Staff were knowledgeable about people's care needs and risk factors, and reflected in the written information we saw in their care records.

The home had a range of daily, weekly and monthly quality monitoring systems in place and had a quality monitoring plan for 2013. This included a variety of ways of seeking meaningful feedback about the quality of life for people at the home. We found that people's care records were accurate and well maintained and that records of staff recruitment had significantly improved.

The home outlined a range of improvements implemented in relation to medicines management. These included further staff training and guidance, weekly checks of medication and discussion of the inspection findings with relevant staff. We looked at five recruitment records which showed all the checks required by the regulations were carried out. We were told about further improvements planned in relation to staff recruitment in relation to staff training and written records. We found the provider was compliant with the two outcomes inspected.

We have received an action plan which detailed improvements being made in relation to the remaining three compliance actions. These will be followed up at a further inspection.