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Inspection Summary

Overall summary & rating


Updated 29 September 2018

We carried out an unannounced inspection of Penhellis on 14 August 2018. Penhellis is a care home which provides nursing care and support for up to 26 predominantly older people. At the time of this inspection there were 22 people living at the service. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service is a detached historical house on two floors with access to the upper floor via stairs or a passenger lift. Some rooms have en-suite facilities and there are shared bathrooms, shower facilities and toilets. Shared living areas include a lounge on the ground floor and first floor, a first-floor reminiscence room and a dining room. The service stands in its own grounds with accessible mature garden areas as well as a central courtyard.

There was a registered manager in post who was responsible for the day-to-day running of the service. 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.

As part of this comprehensive inspection we checked to see if the provider had made the required improvements identified at the inspection of 28 June 2017. In June 2017 we found people’s medicines were not always managed safely. We found several errors which had occurred within the previous month, which did not appear to have been followed up or reported. The registered manager undertook an annual medication audit; however, this was too infrequent to address the errors and areas for improvement that it identified. The medicines room was small, warm and cramped. When nurses were preparing medicines, they needed to prop the door open as it quickly became too warm. The temperature of this room was not being monitored to ensure that the medicines were kept at a suitable temperature. Similarly, the temperature of the medicines fridge was not recorded daily. There was a lack of continuity of nursing care due to a high use of agency and bank nursing staff. This, in part had resulted in one person running out of their prescribed medicines.

At the inspection in June 2017 there was an inconsistent approach to the monitoring of some people’s health conditions meaning it was not always possible to understand if their needs were being met and their treatment was appropriate. People’s rights were not always protected as the principles of the Mental Capacity Act were not always followed. Some people’s records indicated that they lacked capacity to make certain decisions, without saying what the specific decisions were. Nor did the records contain a capacity assessment. Audits to monitor the quality of the service had failed to identify or address the areas of concern identified during our previous inspection in relation to capacity and medication management.

At this inspection we found improvements had been made in all the areas identified at the previous inspection. This meant the service had met all the outstanding legal requirements from the last inspection.

The registered manager had implemented a more robust review and medicines audit system to identify and address any errors more frequently. Medicine audits were being carried out twice weekly by a registered nurse and registered manager. Medicine administration records [MAR] were being checked at the end of every medicines round. When errors had occurred, there was an error log where it was recorded by the nurse, signed and dated. This information identified any particular trends or patterns. For example, it had been noted errors were being found during a specific staff shift pattern by agency staff. The registered manager was abl

Inspection areas



Updated 29 September 2018

The service was safe. Staff knew how to recognise any potential abuse to keep people safe.

Potential risks to people were identified and measures were in place to minimise them.

People received their medicines as prescribed. Staff received training and support to administer medicines safely.

There were sufficient numbers of staff to care for people in a safe way. Recruitment processes included checks so that only suitable staff were employed.

The service was clean and working practices were in place to minimise the spread of any infection.



Updated 29 September 2018

The service was effective. People's health care needs were assessed and monitored and advice was sought from healthcare professionals when required.

People's dietary needs were met. The range of food options promoted their health and wellbeing.

People were supported by staff who had been appropriately trained to understand their needs.



Updated 29 September 2018

The service was caring. Staff communicated effectively with people and treated them with kindness, compassion and respect.

People's privacy and dignity was respected by staff.

Staff showed concern for people's well-being in a caring and meaningful way and responded appropriately to their needs



Updated 29 September 2018

The service was responsive. People received personalised care and support which was responsive to their changing needs. Care plans gave clear direction and guidance for staff to follow to meet people�s needs and wishes.

Staff supported people to take part in social activities of their choice and access the local community.

People and their families told us if they had a complaint they would be happy to speak with the management and were confident they would be listened to.



Updated 29 September 2018

The service was well led. The quality of the service was monitored through regular audits were effective in highlighting areas requiring further improvement.

The registered manager had systems in place to develop and take forward systems to improve people�s quality of care.

People's and relative�s views about the service were sought and acted on.