Penbownder House

Pendownder House is a residential care home providing personal care to 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 34 people using the service. The service was separated in to two units one for people living with dementia and one for people with mental health needs.

People’s experience of using this service and what we found

Medicines were not always managed safely. Some medicines information provided in the care plans was not accurate. Medicines that required stricter controls were not always recorded correctly.

Risks were not always identified or safely managed. An open sharps bin containing used needles and syringes was kept on top of a cupboard in the dining room. People who were living with dementia had easy access to this bin.

Staff did not always have the necessary guidance in care plans to help them support people to reduce the risk of avoidable harm. One person, had assaulted staff and other people living at the service. However, their care plan did not contain any risk assessments to guide and direct staff on how to reduce this identified risk, such as noting specific triggers to the behaviour or detailing what worked to de-escalate the situation.

Everyone in the service had an electronic care plan. However, some information provided on the profile page was not accurate. There was a lack of detail in all the care plans we reviewed. Some guidance provided was not good practice.

Infection control processes and procedures were not always robust. Prior to this inspection the registered manager had agreed to all staff dispensing with the wearing of face masks. Staff were guided to wear a mask when working closely with people such as during personal care. This was not in line with the current guidance. The registered manager took advice and re-instated the wearing of masks.

Visitors were still being asked to make arrangements in advance before visiting loved ones. This was not in accordance with current guidance and we advised the provider that visiting should be entirely open and unrestricted.

The Mental Capacity Act 2005 (MCA) and associated Deprivation of Liberty Safeguards (DOLS) were not always implemented effectively at the service. The registered manager did not have an accurate record showing which people had authorisations in place for restrictive care plans.

Some people had been assessed as requiring pressure relieving mattresses to help ensure they did not develop pressure damage to their skin. These mattresses were not always set correctly for the person using them.

There was very little activity provided for people. There was a ‘magic table’ (the Magic Table is an interactive light projector designed to increase physical and social interactions for people living with dementia) and several headsets to enable people to listen to their choice of entertainment, however, staff confirmed to us, “They are hardly ever used.”

The staff mostly provided task-based interaction with people. On the day of our inspection everyone in the dining room was given the same meal in the same quantities, with no comment made by the staff.

Comments from people about the food where mixed and included, “No choice,” “The food is good, very good, I like it. I just eat what is put in front of me” and “The food is alright sometimes. Not really a choice.”

The registered manager and the provider shared the audit programme providing an overview of the service provided. However, the audit process was not effective and had not identified concerns found at this inspection.

New staff were recruited safely. There were sufficient numbers of staff on shift to meet people’s needs.

Staff were provided with training to ensure they had the knowledge and skills to meet people’s needs. Staff were provided with supervision.

People and their families were provided with information about how to make a complaint and details of the complaint’s procedure were displayed at the service.

People were asked for their views in a survey. The registered manager communicated with families when they visited, or by email.

There was a registered manager at the service at the time of this inspection. The provider supported the registered manager at the time of the inspection.

For more information, please read the detailed findings section of this report. If you are reading this as a separate summary, the full report can be found on the Care Quality Commission (CQC) website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (Published 20 September 2018). At this inspection the rating has changed to requires improvement

Why we inspected

We received concerns in relation to the care provided by staff. We carried out a focused inspection covering Safe, Effective and Well led.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection. We found breaches of the regulations relating to safe care and treatment, consent, person-centred care and good governance.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Penbownder House on our website at www.cqc.org.uk

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Penbownder House accommodates up to 29 people who do not require nursing care. It is an old country house with extensive gardens. The accommodation is split into two units. The older persons unit is located in the main house with accommodation over three floors accessible by passenger lift. At the time of the inspection 14 people were living in this unit. The mental health unit is located in an annex attached to the main house. Nine people were living there at the time of the inspection.

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 service had a full time registered manager in post who worked alongside the director. The director lives in the grounds of Penbownder and was fully involved in the running of the service.

The roles and responsibilities of the registered manager and director were well defined and understood by staff. Staff told us they were well supported by the service’s leadership team and commented, “[The director and registered manager] are approachable you can go to them with any issues” and “You can always go and talk to management if you need to.” Records showed staff had received regular supervision and there were appropriate on call management arrangements in place to enable staff to access support outside of office hours if required.

People were relaxed and comfortable at Penbownder House and told us, “I am happy. I am all right, they are looking after me”, “I get on well with staff here” and “I am looked after well here.”

Staff had received safeguarding training and understood their responsibilities in relation to protecting people from abuse and harm. Issues in relation to a recent safeguarding investigation were discussed with the director. They told us they would update their policies and procedures to help ensure people were fully protected from risk if similar events reoccurred in the future.

Risks to individuals had been assessed. Care plans were sufficiently detailed and provided staff with guidance on how to manage identified risks to ensure people’s safety. When accident and incidents occurred, these were recorded and investigated by the registered manager to identify any changes to procedures that could be made to prevent similar incidents reoccurring.

The well-established staff team were sufficiently skilled to meet people’s care and support needs. Training was regularly refreshed and there were appropriate systems in place for the induction of new members of staff. Staff told us, “I’ve done loads of training” and “They remind you if you are due to refresh anything.”

Records showed planned staffing levels had been routinely achieved and staff told us, “There are enough staff.” Recruitment processes for new members of staff were robust and all necessary pre-employment checks had been completed.

People got on well with their care staff who responded to requests for support without hesitation and provided assistance at a relaxed pace. People told us, “The staff are wonderful, I can speak to them about anything” and “I get on well with staff here, they encourage me to get up and I can always talk to staff if I have any problems.”

People’s medicines were generally managed safely. However, we identified some instances where people were not receiving their medicine with food as recommended. Staff had not been provided with sufficient guidance on how to support people who were receiving their medicines covertly. We have made a recommendation about this in the report..

People needs were assessed before they moved into the service to help ensure those needs could be met. Initial care plans were developed from information gathered during the assessments process. Peoples care plans had been regularly reviewed and updated where changes in people’s care needs had been identified. These documents provided staff with sufficient guidance to help ensure people’s needs were met. The service was in the process of introducing a digital care planning system. The provider’s director told us this system was being gradually introduced, “To make sure we have had the training and feel confident with the system.” In addition, useful care plan summary documents had been developed which were stored in people’s bedrooms and immediately available if required by staff.

There was a part time activities coordinator in post who supported people in both units to engage with a variety of activities. Records showed external entertainers visited regularly. A mini bus and two cars were available to enable staff to support people to access the community when they wished. People went shopping and to visit local beauty spots during our inspection and were regularly supported to attend a memory café in the local town. During our inspection we saw that staff enjoyed spending time with the people they supported taking opportunities throughout the day to support people to engage with individualised activities. One person who was working on a jigsaw puzzle told us, “The staff want to join in and help.”

Staff had a good understanding of the Mental Capacity Act 2005 (MCA). People’s care plans provided staff with information on how to present information to support people to make decisions and where people lacked the capacity to make specific decision the service had consistently acted in the person’s best interests. Where the care plans of people who lacked capacity were restrictive, appropriate applications had been made to the local authority for their authorisation.

The service had a complaints procedure in place to ensure any complaints received were fully investigated. People and their relatives feedback was valued and questionnaires were used regularly as part of the service’s performance monitoring system. Recently completed survey responses had been consistently complimentary and included, “You provide a lovely caring and homely care facility that you and your staff should be proud of” and “I am very confident and thankful for the high standard of care provided.” In addition, regular audits had been completed by the registered manager to identify any areas where improvements could be made in relation to the quality of support people received. The auditing system was designed to drive improvement in the service performance.

The environment was clean and well maintained. Bedrooms were spacious and people were able to access a variety of shared lounges when they wished. In the mental health unit people were able to access the gardens without restriction while in the older persons service staff supported people to enjoy the weather outside when they wished.

Penbownder House provides personal care and support for up to 29 people. There were 27 people living at the home at the time of the inspection. It is not a nursing home. People with the condition of dementia reside in part of the service and people with enduring mental health illness reside in a separate part of the service.

The service had a registered manager in place. 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.

Throughout the inspection there was a calm, friendly and homely atmosphere. People appeared relaxed and happy. People, who were able, spoke highly about the care and support provided.

People were supported to maintain a healthy balanced diet. People told us they enjoyed their meals and did not feel rushed. One person said, “I like the food and there is always lots of it!”

Care records were detailed and recorded people’s preferences. People’s communication methods and preferences were taken into account and respected by staff. People’s risks were considered, managed and regularly reviewed to help keep people safe. Where possible, people had choice and control over their lives and were supported to engage in activities within the home and in the community. .

People were protected by safe recruitment procedures. Staff put people at the heart of their work. We observed the staff were kind, compassionate and gentle in their interactions with people. Good relationships had been developed and practice was people focused, not task led. The service had an open door policy, relatives and friends were welcomed and people were supported to maintain relationships with people who mattered to them.

People who were able to, said they felt there were sufficient staff on duty. People told us “There are always staff here to help me.” Staff were supported with an induction and ongoing training programme to develop their skills and their competency was assessed. A staff member commented; “[…] and […] (the registered manager and registered provider) are always available to help if we are busy.”

The registered provider, registered manager and staff had sought and acted on advice where they thought people’s freedom was being restricted. This helped to ensure people’s rights were protected. Applications were made and advice sought to help safeguard people and respect their human rights. Staff had undertaken safeguarding training, they displayed good knowledge of how to report concerns and were able to describe the action they would take to protect people against harm. Staff were confident any incidents or allegations would be fully investigated. People told us they felt safe.

Some people knew who to contact and how to raise concerns and make complaints. People told us they had not needed to make a complaint but the management team were visible and approachable and would deal with any concerns promptly.

People and staff described the management as very supportive and approachable. Staff talked positively about their jobs and took pride in their work. People told us “It’s really, really lovely here” and “I am very happy here.” A staff member confirmed “I left but liked it so much I came back!”

The service had an open and transparent culture. The provider had set values that were respected and adhered to by staff. Staff felt listened to and were encouraged to share any concerns they had so issues could be promptly dealt with. The staff worked closely with external agencies such as the local authority to raise issues and seek advice promptly when required.

People’s opinions were sought formally and informally. Audits were conducted to ensure any concerns with the quality of care and environmental issues were identified promptly. Accidents and safeguarding concerns were investigated and where there were areas for improvement, these were shared for learning.

People’s medicines were managed safely. Medicines were managed, stored, given to people as prescribed and disposed of safely. Staff were appropriately trained and confirmed they understood the importance of safe administration and management of medicines.

People lived in a home that was clean and hygienic. The premises were well maintained and comfortable.

People had access to healthcare professionals, such as district nurses and GPs, to make sure they received appropriate care and treatment to meet their health care needs. Staff acted on the information given to them by professionals to ensure people received the care they needed to remain safe. Surveys returned to the service recorded that; “The health, wellbeing and appearance of [….] had improved since being at Penbownder.”

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, the staff supporting them and from looking at records.

Is the service safe?

People told us they felt safe. Systems were in place to help the manager and staff team learn from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. This reduced the risks to people and helped the service to continually improve. Staff showed a good understanding of the care needs of the people they supported.

Penbownder alerted the local authority and the Care Quality Commission when notifiable events occurred or they had any concerns regarding people who used the service. Penbownder had policies and procedures in relation to the Mental Capacity Act 2005 (MCA) and the associated Deprivation of Liberty Safeguards (DOLS). This helped to ensure that people's needs were met.

Is the service effective?

People's health and care needs were assessed with them where possible and in some cases with the input from relatives. During our inspection it was clear from our observations and from speaking with staff, and relatives of people who used the service, that staff had a good understanding of people's needs.

Specialist dietary needs had been identified where required. Care plans were up-to-date.

We saw there was good liaison and communication with other professionals and agencies to ensure people's care needs were met.

The quality of recording seen was of a good standard enabling care staff to use the information correctly.

Is the service caring?

We spoke with five people and asked them for their opinions about the staff that supported them. Feedback from people was positive, for example, 'wonderful' and 'Staff are very friendly' and 'Very considerate carers'. When speaking with staff it was clear that they genuinely cared for the people they supported.

People's preferences and interests had been recorded and basic life histories were evident.

Penbownder had regular support from the GPs from the local GP practices and other visiting health professionals. This ensured people received appropriate care in a timely way.

Is the service responsive?

Many people who lived at Penbownder had complex health and care needs and were either not able, or chose not to join in group activities. The care records showed evidence of the lifestyle of these people and we observed that staff spent one-to-one time with people throughout the day.

The home had recently employed an activity enabler. During our visit we observed people being taken out for a walk in the extensive grounds. We observed staff spending quality time with people during the afternoon of our visit.

The service worked well with other agencies and services to make sure people received care in a coherent way.

Is the service well-led?

We saw minutes of regular meetings held with the staff. This showed the management consulted with staff regularly to gain their views and experiences and improve support for people who lived at the service.

The service had a quality assurance system, and staff told us they were clear about their roles and responsibilities. Staff had a good understanding of the ethos of the home and quality assurance processes that were in place. This helped to ensure that people received a good quality service at all times.

People told us, "...wouldn't want to be anywhere else." People told us they were treated kindly and with care. They told us they were very happy living at Penbownder and that they were treated with consideration and respect. We saw people being encouraged to be independent where possible and supported where this was needed. Detailed care plans enabled staff to meet people's needs. People told us about activities they engaged in and we saw staff interacting with people in a person centred manner.

The staff we spoke with understood how to protect people and how to raise concerns if they had any. Staff had an induction period, they were trained in safeguarding and understood that some people needed support to make decisions about their care and welfare. Staff received comprehensive training in a variety of physical and mental health areas. This enabled them to provide the care people needed. They told us they felt supported by their colleagues and the management. We saw staff caring for people confidently and in a calm, unhurried manner explaining what they were doing and why.

The Nominated Individual had a system in place for monitoring the quality of the service to ensure the standards of care remained high. We saw evidence of good practice guidance being implemented in the dementia unit.