Penbownder House

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement.

At this assessment the rating has remained requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

Governance systems were not effective, and managers had failed to act on audits or identify areas of improvement following incidents that occurred.

The service was in breach of the regulation in relation to governance at the service.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff were well motivated and enjoyed their roles at Penbownder. They told us, “The culture is good amongst the staff and we all support each other”, “They are residents but they also become family, we treat them as you would like to be treated yourself” and “It is good here. The residents and the colleagues are really nice and colleagues are really supportive and management are really good so we can share any problems and can discuss with them.”

The registered manager valued the commitment of their staff team and told us, “I am proud of the staff that I have”.

Not all leaders understood the context in which the provider delivered care, treatment and support. They had not recognised people’s opportunities were limited in some areas of the service.

The service’s performance had improved since our last inspection. The registered manager and the provider’s director led the staff team effectively. Systems for supporting staff outside of office hours were effective. Staff were complementary of their leaders and told us, “We know we can escalate to the manager and the owner always says you can call [them]”, “I would rather work here than anywhere else” and “[The registered manager and Deputy manager] manage it well here”.

However, the quality of care and support across the service did not always meet the required standards. Leaders had failed to recognise that people whose voices were harder to hear did not have the same access to opportunities as others in the service.

The registered manager told us they were well supported by the provider’s director, who visited the service regularly, and the recently appointed deputy manager. The roles and responsibilities of individual managers were well understood by staff. Professionals told us, “[The registered manager] is lovely and seems to have a good knowledge of people”.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Managers engaged with people and visiting relatives routinely and valued their feedback. Relatives told us, “Communication has been really good, I feel know what's going on and I can always ring and ask.”

Staff meetings were held regularly and provided opportunities for information to be shared and areas of learning or improvement to be identified.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff valued the diversity of their team and reported all staff were treated fairly by managers. Their comments included, “The staff welcomed me and all staff are treated fairly and equally” and “We have staff from many backgrounds and it is a good mix and we respect all backgrounds.” Relatives also appreciated and valued the quality of support provided by the service’s diverse workforce and recognised this had helped their relative overcome some prejudices.

Managers were proud of their staff and how they supported each other. Staff said managers respected their religious and cultural needs and responded positively to requests for reasonable adjustments to working practices.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider’s governance systems were not entirely effective and had failed to ensure the service fully complied with the requirements of the regulations.

Audits were being completed but these processes were not sufficiently robust to drive improvement in the service’s performance. For example, audits of the services electronic Medicine Administration Record (eMAR) system had identified discrepancies in the number of tablets recorded in the system when compared to amount held in stock. These issues had not been investigated to identify the cause of the identified discrepancies. Following feedback, the registered manager reviewed these discrepancies and identified additional issues with the accuracy of information recorded in the eMAR system. As a result, the use of the eMAR system was subsequently suspended and paper-based MARs reintroduced.

Infection control audits had not identified risks associated with uncovered bins or the storage of towels on open shelves in communal bathrooms. Necessary notifications had not been submitted to the CQC as required by law. Spot checks completed by the registered manager to monitor staff performance outside of office hours had not been documented. This meant any themes relating to staff performance might not be recognised.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and acted on guidance given.

The service worked collaboratively with health professionals and partner organisations to ensure people’s needs were identified and addressed. Prompt referrals had been made and advice provided acted upon. Staff told us, “The doctors come in and we always have notes of what they have said so we can read up on it in the care plans. We have a good relationship with the District Nurses.”

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people.

The service had not learned from a recent incident where a person, subject to a DoLS authorisation, had exited the service via a window on which a restrictor had failed exposing the person to significant risk of harm. Following that incident no formal processes had been introduced to ensure all widow restrictors remained operational and no audit had been completed to ensure all windows were fitted with operational restrictors.

During the assessment visit an unrestricted window was identified. This risk was highlighted to the registered manager and a restrictor was promptly installed to ensure people’s safety.