Penhellis Nursing Home

Penhellis is a care home which provides nursing care and support for up to 26 predominantly older people. At the time of the inspection 20 people were living at the service.

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

People who lived in the service told us they were happy and safe. One person said, “This was a place of choice for me and my family”. Another said, “Staff have been here a long time. They take their time and are gentle, I think they do their very best, we have a nice banter”.

People looked relaxed, happy and comfortable with staff supporting them. Staff were caring and spent time chatting with people as they moved around the service.

The environment was safe, regularly updated and there was equipment available to support staff in providing safe care and support. Health and safety checks of the environment and equipment were in place.

People were supported to access healthcare services, staff recognised changes in people's health, and sought professional advice appropriately. Records were accessible and up to date. Medicines were ordered, stored and disposed of safely.

Staff received appropriate training and support to enable them to carry out their role safely, including fire safety and dementia care training. Staff were recruited safely in sufficient numbers to ensure people’s needs were met. There was time for people to have social interaction and go out into the community. Staff knew how to keep people safe from harm.

Cleaning and infection control procedures had been updated in line with COVID-19 guidance to help protect people, visitors and staff from the risk of infection.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Records of people's care were individualised and reflected each person’s needs and preferences. Risks were identified, and staff had guidance to help them support people to reduce the risk of avoidable harm. People’s communication needs were identified, and where they wanted, people had end of life wishes explored and recorded.

People and staff told us the registered manager and the management team made themselves available and assisted them daily. They went on to say how they were approachable and listened when any concerns or ideas were raised.

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.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was good. (Published 29 September 2018).

Why we inspected

This inspection was prompted by a review of the information we held about this service. We had identified we and the local authority had not been notified of a safeguarding concern in the service.

A decision was made for us to inspect. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only. 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 not changed and remains good. We found no evidence during this inspection that people were at risk of harm from the information we held. Please see the safe, effective and well led sections of this report.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

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 able to address this with the supplying agency as they were not part of the services staff team.

The medicines room remained as the previous inspection. A small compact room where staff could only work with the door propped open. There were proposals in place for it to be resited as part of a planned extension of the service. However, in the interim period a fan had been put in place and daily temperature checks were being made and recorded. The records showed the rooms temperature had been satisfactorily maintained. Daily fridge temperatures were now being monitored and were satisfactory.

The registered provider had recently installed a surveillance system in the medicines room. There was a policy statement telling people using the room about the purpose of collecting information here, how the information will be accessed and stored. Also, there was a sharing of information protocol. Staff told us they were made aware of this system as were people using the service or where they lacked capacity their legal representatives. There was signage in the room to alert people to this system.

The service was being staffed satisfactorily. There remained a reliance on agency staff, however the service had managed to increase its level of bank staff which meant there was generally a level of continuity. Nobody told us they were concerned about the consistency of staff or staffing levels. Staff said there were times that were particularly busy but that they worked as a team which meant they worked together to meet people’s individual needs.

Care records were being reviewed and changes made to respond to risk. The records we viewed demonstrated the information was in good order and it was easy to find the relevant section within. There was a numerical Index at the front and each section that made it was easy for staff to navigate and find the information they needed.

Where people lacked metal capacity there was evidence to demonstrate the service acted in accordance with the Mental Capacity Act [MCA]. In order to meet the breach from the inspection in June 2017 the service had introduced a revised assessment tool. This had been used to record people’s capacity and identify any issues. Best interest meetings were taking place and applications sent to the local authority where necessary for the authorisation of restrictive care plans.

Throughout the inspection we observed staff providing support with respect and kindness. People generally told us they felt safe and comfortable living at Penhellis. Comments included, “Life is very calm and predictable, everything is spotlessly clean and the staff are always discretely on hand to help me.” and “I’m so glad I chose to live here. It’s just a lovely place to be.” Two people told us they had experienced staff members speak with them in a way they found disrespectful. They had reported these issues to the registered manager and they had not reoccurred. Staff records showed these issues had been addressed with staff through personal supervision.

People received care and support that was responsive to their needs because staff had the information to support them. Staff supported people to access healthcare services. These included, social workers, psychiatrists, general practitioners (GP) and speech and language therapists (SALT). In addition, people could choose complimentary therapies including Reiki, Indian Head Massage, acupuncture and herbal medicine. These additional services incurred additional charges which were displayed in the welcome pack.

Staff were sufficiently skilled to meet people’s needs. Necessary pre-employment checks had been completed and there were systems in place to provide new staff with appropriate induction training. Existing staff received regular training, supervision and annual performance appraisals.

Safeguarding procedures were in place and staff had a good understanding of how to identify and act on any allegations of abuse.

There was a system in place for receiving and investigating complaints. People we spoke with had been given information on how to make a complaint and felt confident any concerns raised would be dealt with to their satisfaction.

The manager used effective systems to record and report on, accidents and incidents and take action when required.

The service was suitably maintained. It was clean and hygienic and a safe place for people to live. We found equipment had been serviced and maintained as required.

Staff wore protective clothing such as gloves and aprons when needed and there were appropriate procedure in place to manage infection control risks.

Meals were appetising and people were offered a choice in line with their dietary requirements and preferences. Where necessary staff monitored what people ate to help ensure they stayed healthy.

The provider had systems in place to monitor the quality and safety of the service.

This inspection took place on 28 June 2017 and was unannounced.

Penhellis nursing home provides accommodation, personal and nursing care for up to 26 people. On the day of our inspection, there were 22 people living at the service.

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.

People’s medicines were not always managed safely. We found several errors which had occurred within the past 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. We found that 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.

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. We found that topical cream charts in people’s bedrooms were not always completed. We found evidence of pressure care, however it was not always consistent. We found two people’s records contained a comprehensive set of documentation, whilst another was missing a pressure area and wound assessment form. Some people had food and fluid charts in their rooms. We saw examples where these charts were inconsistently completed and there was no balance at the end to calculate the person’s intake.

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. Where people were considered to lack capacity, we saw no evidence of best interest processes to ensure that decisions taken on their behalf were the least restrictive available, or in the person’s best interests. We saw examples where relatives had signed documents to consent to elements of people’s care and treatment without the legal authority to do so.

Mealtimes were sociable and relaxed with staff on hand to provide assistance as required. Feedback on the meals was mixed. Some people told us they enjoyed the food, whilst other feedback was less positive. We have made a recommendation about this.

We found there were occasions when there was not a cook on duty to prepare meals for people due to a staff vacancy. This meant there was a reliance on food such as pasties and fish and chips being brought in on those days.

The environment was extremely well maintained. There were areas which were dementia friendly, such as a room with vintage reminiscence items for people to access to relax. We noted some antique items such as clocks, many of which did not state the correct time. This was discussed with the registered manager as it may have been confusing for those living with dementia. There was also a lack of signage around the home to orientate people with memory impairments. The building was secure and people told us they felt safe living there. The service was visibly clean and free from adverse odours.

The registered manager undertook audits to monitor the quality of the service. However these had failed to identify or address the areas of concern we found during the inspection in relation to capacity and medication management. The infrequency of the registered manager’s medicines audit had meant that she had not realised that clinical staff were not undertaking the regular audits of medicines they were required to.

People told us they felt safe at Penhellis. People were supported by staff who understood how to recognise and report any signs of suspected abuse or mistreatment. Staff had been safely recruited, and had undergone checks to help ensure they were suitable to work with people who were vulnerable. During the inspection, we observed suitable staffing levels. This meant staff were available to meet people’s needs in an unhurried way. People were supported by staff who had undergone training to help ensure they could meet their needs effectively.

People’s care records were comprehensive, detailed and regularly reviewed and updated. Care plans contained personalised information to help staff understand how to provide care which was reflective of their preferences. People were provided with opportunities to engage in a variety of activities as well as personalised, one to one time. There were visitors to the service, such as church ministers and singers.

People had access to a range of health and social care professionals and this was evidenced in their care records. Prompt referrals were made to external agencies when required, for example, we saw referrals to speech and language therapy services (SALT) and tissue viability services. .

Staff were supported by a thorough induction process which including shadowing more experienced staff. During their induction, staff familiarised themselves with people’s care records so they had a good understanding of the needs of those they were supporting. All staff were supported by an on-going programme of supervision as well as an annual appraisal.

Staff knew the needs of the people they supported well and were able to describe their likes, dislikes, history and routine. Staff spoke about the people they supported with fondness and affection. People’s dignity was protected by staff who were respectful and compassionate. The atmosphere at the service was pleasant and relaxed and people appeared comfortable and at ease. People’s confidential information was stored in the staff room, which was protected by a lock, however, all staff including kitchen, domestic and maintenance staff had access to this room.

As part of our inspection we spoke and met with the registered manager, the deputy manager, a nurse and a variety of care staff. The registered manager and deputy manager confirmed they were aware of the concerns which had been raised and had been working with Social Services to provide essential information.

People who lived at Penhellis Nursing Home were complimentary of the care and support they received. Those we spoke with told us staff treated them with dignity and respect, particularly when they supported them with personal care. Comments included, 'overall you get excellent care here' and 'generally everything is okay'.

We found care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare.

Following our inspection we liaised with Social Services to advise of the outcome of our inspection.

Each person had a care plan in place which stated their individual needs. Manual handling training had been completed for most staff to ensure people were assisted to mobilise safely.

People had access to a range of services including a hairdresser, chiropodist and GP's.

The home was clean and there was a robust system in place to ensure the risk of infection was reduced.

The home had sufficient recruitment processes in place to ensure the people who lived at Penhellis were cared for and supported by staff that were of good character.

The provider had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who used the service and others.

Care plans did not always reflect the manual handling practices that were completed by staff.

People were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening.

People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines.

People were supported by staff that were supported to deliver care and treatment safely and to an appropriate standard.

The provider had an effective system to regularly assess and monitor the quality of service that people receive.