Updated 14 May 2025
Date of assessment: 12 March to 17 March 2025.
Penbownder House is a residential care home providing personal care for up to 34 people. The service provides support to younger adults, people with mental health needs, older people and people living with dementia. At the time of our inspection there were 29 people using the service.
The inspection was carried out to assess the safety of the service following an incident where a person had left the service via a ground floor window and to check if improvements had been made following our last inspection. At that inspection we identified breaches of regulations relating to person-centred care, the need for consent, safe care and treatment and management and oversight of the service. We rated the service requires improvement for our key questions, Safe, Effective and Well-led.
At this assessment we looked at all quality statements under the 5 key questions; Safe, Effective, Caring, Responsive and Well-led. We found the service’s performance had improved and that it was no longer in breach of the regulations in relation to the need for consent and safe care and treatment. However, although some improvements had been made in the service's performance it remained in breach of the regulations in relation to the quality of person-centred care in some areas of the service and the management and oversight of the service. Following this assessment we have rated the service Requires Improvement.
The service did not have robust systems to identify learning following incidents that occurred. Additional checks had not been completed following an incident where a person left the service without support via a window. An unsecured window was identified during the inspection, this was promptly addressed.
Infection control guidance was not consistently followed, and audits had failed to identify issues in relation to lack of bin covers and storage of towels in shared bathrooms.
The service did not ensure a bathroom people used independently was regularly cleaned.People were given eye drops and nasal sprays while eating at a communal table. This meant people’s dignity was not consistently protected.
People in different areas of the premises did not have equal access to activities. On the ground floor of the older persons service, and in the mental health service, people were supported to engage with a range of appropriate activities. However, on the first floor of the older persons service, care was task based and there were limited opportunities for people to take part in activities. Relatives told us puzzles and games were missing pieces and impossible to use.
Quality assurance systems were not entirely effective and had not ensured compliance with the regulations. Where managers had identified issues, for example in relation to discrepancies in tablet counts on the electronic Medicines Administration Record (eMAR) system, these had not been explored to identify the cause. Following feedback these issues were investigate and use of the eMAR system discontinued.
People were protected from abuse and there were sufficient numbers of staff available to ensure people’s safety and meet their needs. Risk assessments had been completed and staff were provided with clear guidance on how to mitigate risks associated with their care and support needs. People received their medicines as prescribed.
The service was appropriately maintained, fire drills had been completed and utilities checked and serviced regularly to ensure safety.