Penley Grange

Penley Grange is a residential care home. The service was supporting five people at the time of our inspection and can support up to six people. The service is adjoined to a separately registered care home operated by the same care provider.

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

People did not always live safely. This was because the service did not assess, monitor or manage people’s safety well, including risks of abuse and risks posed by the behaviours of people using the service. The service had failed to consistently make contact with other relevant agencies, when incidents or concerns occurred, to protect people from the risk of abuse. Where concerns had been identified and reported, this had not always been achieved in a timely manner.

Staff members did not always treat people with kindness, dignity and respect, including respect for people’s privacy. People were not consistently supported to express their wishes and engage with staff using their preferred methods of communication.

Staff recruitment, induction and ongoing training processes did not promote safety, including those for agency staff. The skills and deployment of staff did not match the needs of people using the service.

People did not have opportunities to learn new skills or try new experiences due to the limited variety of on-site and off-site activities people were supported to participate in. Care plans were not holistic, strengths-based and did not capture people’s preferences and aspirations. We have made a recommendation in relation to end of life care planning.

People’s relatives told us they had generally been involved in key decision making, however records showed the service did not consistently consult people’s relatives when accidents or incidents occurred. Relatives felt communication could be improved, although indicated there had been some recent signs of improved communication since a care consultancy was engaged to help manage the service, including contact with relatives about some incidents which had occurred.

Governance processes had not been operated effectively to keep people safe, provide good quality care and protect people’s rights. A care consultancy had recently been commissioned by the provider to develop an action plan and support the service to make improvements. At the time of our inspection we observed environmental works taking place but a number of other planned changes had not yet been implemented, or were not yet embedded, meaning we could not observe significant improvements to people’s experience of using the service. We have also made a recommendation in relation to the provider’s responsibility to meet the duty of candour.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the service had purchased a new suite of policies which were due to be implemented to promote best practice.

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

The service was not able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture.

Right Support

People were not consistently supported by staff to pursue their interests, or to identify their aspirations and goals. Staff did not always communicate with people in ways that met their needs. People were not supported in a safe, well-maintained environment that met their sensory needs.

Right Care

People did not always receive kind and compassionate care. Staff did not consistently take action to protect and respect people’s privacy and dignity. Staff did not consistently understand and act to protect people from poor care and abuse.

Right culture

People were not supported to lead inclusive and empowered lives. The service had failed to consistently evaluate the quality of support provided to people or ensure risks of a closed culture were minimised so that people received support based on transparency, respect and inclusivity.

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

Rating at last inspection

The last rating for this service was Good (published 8 November 2017).

Why we inspected

We undertook this inspection to assess that the service is applying the principles of Right support right care right culture. The inspection was prompted in part due to concerns about poor management oversight following concerns raised about the quality and safety of people’s care at the adjoined care home. We had also received concerns in relation to the service, including concerns about the quality of people’s care, staff culture and management of risks.

We have found evidence that the provider needs to make improvements. Please see the safe, effective, caring, responsive and well-led sections of this full report. You can see what action we have asked the provider to take at the end of this full report.

The overall rating for the service has changed from good to inadequate based on the findings of this inspection.

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

Enforcement and Recommendations

We have identified breaches in relation to safe care, safeguarding from abuse, person centred care, dignity and respect, consent to care, staffing levels and suitability, nutrition and hydration, suitability of the environment, management of complaints, staff training, governance and leadership and reporting of incidents.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an updated 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.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

The service was previously inspected on 23 and 24 May 2016 and was not meeting the requirements of the regulations at that time. The service was in breach of Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was in relation to medicines practice, staff recruitment, monitoring the service and record keeping.

During this inspection we found improvements had been made and the service was meeting the relevant requirements.

Penley Grange provides care and support for up to six people with learning disabilities. Six people were living at the service at the time of our inspection. The service was being managed by one of the provider’s registered managers from one of their other services at the time of our inspection. An application for them to become the registered manager at Penley Grange had been submitted.

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.

We received mainly positive feedback about the service. Comments we received were, “I am quite happy with Penley Grange and I feel my family member is safe there” and “Yes she is safe as she has a tendency to want to run away and she can’t because the security is really good.”

We found medicines were managed safely. Medicine charts we viewed were completed correctly and staff had received relevant training in medicine administration.

We found there were sufficient staff to meet people’s needs. Staff knew the people they were supporting and interacted well with them in a way that was relevant for each person. For example some people could not communicate and specific aids were used such as Makaton and picture cards.

Staff received safeguarding training to ensure they recognised the signs of abuse and were able to respond to safeguarding concerns to the relevant local authority.

Staff received on-going training to ensure they were knowledgeable to meet the needs of people. New staff received an induction followed by regular supervision.

Care plans had been written to ensure the individual needs of people were met. Preferences were documented for how people wished to be supported. People were supported to have maximum choice and control of their lives and staff supported them in the least restricted way possible; the service had policies and procedures to support this. People were treated with dignity and respect and we saw they were given choices.

Staff supported people to attend healthcare appointments. People were supported to take part in a range of activities. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

Monitoring systems were in place to identify where improvements could be made. Records were maintained to good standards and were easily located.

Evacuation plans were in place in the event of a fire and had been written for each person to support them safely. On the first day of our visit we were told where to assemble in the event of a fire.

We previously inspected the service on 23 January 2015. The service was meeting the requirements of the regulations at that time.

Penley Grange provides care for up to six people with learning disabilities. Five people were living at the home at the time of our visit.

The service had 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.

We received positive feedback about the service. Comments included “It’s a lovely home,” “Staff are absolutely lovely and friendly,” “Staff are very kind,” “Residents always look well turned-out and very happy” and “The care is generally very good.”

There were safeguarding procedures and training on abuse to provide staff with the skills and knowledge to recognise and respond to safeguarding concerns.

We found people’s medicines were not handled safely. For example, there were gaps in medicine administration records and staff had given an incorrect dose of one person’s medicine.

We found there were sufficient staff to meet people’s needs. We saw they interacted well with people and took an interest in them. Staff recruitment procedures were not robust enough to make sure people were supported by staff with the right skills and attributes.

Staff received support through a structured induction and supervision There was an on-going training programme to provide and update staff on safe ways of working. We have made a recommendation to ensure the service follows good practice in the supervision and development of staff.

Care plans had been written, to document people’s needs and their preferences for how they wished to be supported. These had been kept up to date to reflect changes in people’s needs. People were supported to take part in a range of social activities. Staff supported people to attend healthcare appointments to keep healthy and well.

The building was well maintained. Evacuation plans had been written for each person, to help support them safely in the event of an emergency. Staff told us where to assemble in the event of the fire alarm sounding. We have made a recommendation to ensure people are protected from environmental risks at the service.

There were clear visions and values for how the service should operate and staff promoted these. For example, people were treated with dignity and respect and we saw they were given choices.

Monitoring and auditing systems were not always robust enough to identify where the service needed to improve practice.

We found records had not been maintained to a good standard and were not always easy to locate; some needed to be sent to us after we visited the service.

We found breaches of the Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were in relation to medicines practice, staff recruitment, monitoring the service and record keeping. You can see what action we told the provider to take at the back of the full version of this report.

We set compliance actions for the provider to improve practice. The provider sent us an action plan which outlined the changes they would make to become compliant.

We returned to the service on 26 January 2015 to check whether improvements had been made. This was after the date the provider told us all actions to improve the service would be completed.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the questions we always ask:

' Is the service safe?

' Is the service effective?

' Is the service well-led?

This is a summary of what we found -

Is the service safe?

We found Penley Grange provided a safe service. The home now had effective systems in place to reduce the risk and spread of infection. The premises were kept clean throughout. Shared bathrooms and an en-suite bathroom had been refurbished. Appropriate disposal bins were in place for clinical waste, to make sure it was handled safely. There were different coloured laundry skips to separate contaminated linen and clothing to help reduce the risk of infection.

We saw improvements had been made in the kitchen. For example, staff were no longer placing their bags and coats on the disused stove and they wore disposable aprons and gloves when handling food. Food storage areas were in good order with the date of opening added to packets of food. This helped ensure food was only consumed when it was safe to eat.

Is the service effective?

We found Penley Grange provided an effective service. The manager had put systems in place to make sure staff received supervision. This provided a forum to discuss how staff were working and to identify any training or development needs. Staff meetings had also been held to share ideas and promote best practice.

Staff training needs had been looked at. The manager said some staff had completed recent courses on safeguarding, the Mental Capacity Act (2005) and deprivation of liberty safeguards. Further staff would be completing these courses as places became available. The manager was also arranging for training on autism spectrum disorder and maintaining records, to increase skills and knowledge.

Is the service well-led?

We found Penley Grange provided a well-led service. The provider had visited the home each month to assess the quality of care and had carried out audits. For example, on medication practice, infection control and catering. These showed that people were receiving good standards of care.

A new manager had been appointed. We saw they had made improvements to how the home was run. For example, a daily tasks form had been set up to record which staff had been allocated to assist each person with their personal care. It also recorded which staff were responsible for ensuring tasks such as laundry and cleaning were completed. This helped to ensure all necessary actions were undertaken on each shift.

We found improvements had been made to notifying the Care Quality Commission about serious incidents. The manager had informed us of a safeguarding concern and had completed the necessary documents. The manager was aware of other serious incidents that needed to be reported to us. This meant people could be confident that important events that affected their welfare, health and safety were reported to the Care Quality Commission so that, where needed, action could be taken.

' Is the service caring?

' Is the service responsive?

' Is the service safe?

' Is the service effective?

' Is the service well-led?

This is a summary of what we found -

Is the service safe?

We found Penley Grange needed to take action to provide a safe service.

CQC monitors the operation of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). There was one current DoLS in place, which had been authorised by the local authority. This ensured there were proper safeguards in place where restrictions were placed on people. We noted the most recent record of authorisation was extended by the local authority until 6 February 2014. The provider may find it useful to note there was no record at the home of authorisation beyond this date. This would be needed to verify the restriction remained lawful.

We found there were sufficient staff to meet people's needs. The manager position was vacant and recruitment was underway at the time of our inspection. Relatives we spoke with described staff as 'Very, very nice,' and 'Lovely, friendly, helpful.'

When we visited the service on 6 February 2014, we had concerns about standards of record keeping. We set a compliance action for the provider to improve practice. The provider sent us an action plan which outlined the changes they would make to become compliant. We used this visit as an opportunity to check that sufficient improvements had been made.

We found improvements had been made to records. People's personal records were accurate and fit for purpose. Dates were now included on people's personal records. This enabled the most up to date version of a document to be identified. The records we asked to see during the visit were located promptly. The only records not provided were reports of monitoring visits by or on behalf of the provider.

We had concerns about infection control practice at the home. The building had not been kept clean in several areas. For example, one person's en suite shower room had a stained shower curtain, stained shower chair and stained shower cubicle. The toilet bowl was very stained below the water level. These areas provided places where bacteria and other harmful microbes could breed, which placed people at risk of infection. There were also issues about cleanliness in a communal bathroom and other areas of the home, which needed to be addressed.

Is the service effective?

We found Penley Grange needed to take action to provide an effective service.

There were systems in place for the induction and training of staff. This ensured they had the right skills and knowledge to meet people's needs. Staff had not received the support they required to carry out their roles effectively. Supervision sessions and appraisals had not taken place routinely at the home. This may have led to inconsistencies in people's care.

Is the service caring?

We found Penley Grange provided a caring service.

People's needs were assessed and care was planned and delivered in line with their individual care plan. We saw care plans were in place for each person. We read two people's care plans. Both contained comprehensive assessments of the person's needs and any support they required. This helped ensure people received the support they needed.

We spoke with two relatives. Both were pleased with the standards of care at the home. One said their relative was 'Looked after well.' Another told us 'They've supported him very well.' They added 'Any concerns we've had have been dealt with' and 'He is happy to go back there after we've been out.'

Is the service responsive?

We found Penley Grange provided a responsive service.

We observed staff welcomed people back from day services and offered them drinks. Each person had been supported to dress appropriately for warm weather. We saw people were free to spend time in places of their choice, such as their room, the sensory room and the extensive gardens. We heard staff talking to people and taking an interest in them and what they had done during the day. Repetitive questions were answered patiently and politely.

There were arrangements in place to deal with foreseeable emergencies, such as a fire at the home. Care was planned and delivered in a way that was intended to ensure people's safety and welfare. We saw risk assessments had been written for a range of activities and situations. For example, accessing the community, choking and managing behaviour. These assessments had been kept up to date to ensure information was current and reflected people's circumstances. This helped reduce or control the potential for people to experience harm.

Is the service well-led?

We found Penley Grange needed to take action to provide a well-led service.

We saw learning from incidents / investigations took place and appropriate changes were implemented. A report had been made earlier in the year of missing money, belonging to someone who used the service. The provider looked into this and found the money had been logged inappropriately, but was not actually missing from the home. Since that time, a new system had been set up to safely store and record people's money. This helped ensure there was better management of people's money. However, providers and managers are required to notify us of certain incidents which have occurred during, or as a result of, the provision of care and support to people, such as the report of missing money. The provider had not notified us of this incident and they were unaware of the need to do so. This meant people could not be confident that important events that affected their welfare, health and safety were reported to the Care Quality Commission so that, where needed, action could be taken.

The provider told us there was someone within the organisation who visited the home to monitor quality of care. We asked for copies of reports of these visits to be sent to us. We did not receive any evidence to show the visits took place. We could not, therefore, be confident the provider had an effective system to monitor the quality of people's care.

We saw records which showed four audits had been undertaken at the home this year. These focussed on care plans, catering, infection control and medication. We noted deep cleaning and regular shampooing of carpets was identified on the infection control audit, carried out in March this year. There was no further audit to check this had been done. Our inspection findings showed they had not been actioned.

In this report the name of a registered manager appears who was not in post and not managing the regulatory activity at this location at the time of the inspection. Their name appears because they were still a registered manager on our register at the time.

People were offered a rewarding lifestyle and were happy living in the home.

We saw that people were well cared for and treated with respect and dignity.

The home was clean but was not 'homely' and was in need of some refurbishment. We saw that the home took health and safety seriously and kept people as safe as possible.

We found that there were enough properly trained staff to meet people's individual needs.

We saw that the home had ways of looking at the care they offered so that they could make sure they maintained and improved it. They listened to the views of the people who lived in the home.

We found that some important records were not dated and not available to staff , who needed access to them.

We observed a calm and pleasant home with purposeful activity. We saw bright spacious rooms which were personalised and appropriate to the age group. During our visit, we heard positive interactions between staff and people who live there, and saw staff provide a high level of emotional support to a young person using the service. This demonstrated a high regard for the individual's preferences.

We read care plans, and heard that people went on visits to their families at the weekend. The families remained involved in the daily welfare of people who use the service; this denoted that people's views and experiences were taken into account in the way the service was provided and delivered in relation to their care.

Staff we spoke with were trained in the Safeguarding of Vulnerable Adults. They said they had seen no abuse in the home, and were able to demonstrate the correct procedure to escalate any concerns. Staff had requested some additional training which was being addressed by the manager.

There was a complaints procedure in place. We heard how complaints were dealt with, and noted none had been received in the last year.