Penley View

Updated 26 May 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection site visit was completed by three inspectors. An additional inspector completed phone calls to staff after the site visit. An Expert by Experience contacted families of the people who use the service. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Penley View is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Penley View is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was not a registered manager in post. However, a new manager had been in post for 11 months and had submitted an application to register. The manager supported us on both days of inspection. We will refer to them as ‘the home manager’ throughout the report. After the inspection, we were informed the home manager had been approved as the registered manager.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

Prior to the inspection we looked at all the information we had collected since the last inspection of the service including information from the local authority and notifications sent to us. A notification is information about important events which the service is required to tell us about by law. We reviewed the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke to the home manager and the deputy manager. Two consultants were supporting the inspection as the nominated individual’s representatives. We observed interactions between staff and people. We reviewed a range of records relating to the management of the service, for example, records of medicines management, risk assessments, accidents and incidents, quality assurance systems, and maintenance records. We looked at 2 people's care and support plans and associated records. We looked at recruitment information for 7 staff in total. We spoke to the nominated individual as part of the feedback session at the end of both days of inspection. The nominated individual is responsible for supervising the management of the service on behalf of the provider. After the inspection we spoke to 2 relatives of the people who use the service and 9 members of the staff team. We continued to seek clarification from the home manager to validate evidence found. We contacted 8 professionals who work with the service for further feedback.

Updated 26 May 2023

About the service

Penley View is a residential care home providing personal care to 2 people at the time of the inspection. The service can support up to 6 people.

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

Right Support:

We judged that 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. However, the policies and systems in the service required improvement to continue supporting this practice.

The provider did not use safe recruitment procedures to employ staff. Therefore, there was a risk people could be supported by unsuitable staff putting them at increased risk of harm.

Staff supported people with their medicines in a way that promoted their independence. However, other aspects of medicine management such as record keeping, and checks needed improvement.

The service gave people care and support in a safe, well-furnished environment that met their sensory and physical needs. However, some aspects of premises safety such as cleaning records and practice needed some improvement.

Staff supported people to take part in activities. However, further improvements were needed to ensure people could pursue their interests in their local area with people who had shared interests and achieve their aspirations and goals.

People had a choice about their living environment and were able to personalise their rooms. The service and staff supported people to have the maximum possible choice, control and independence over their own lives. Staff focused on people’s strengths and promoted what they could do, so people had a fulfilling and meaningful life.

Staff enabled people to access specialist health and social care support in the community. Staff supported people to play an active role in maintaining their own health and well-being.

Staff supported people to make decisions following best practice in decision-making. Staff communicated with people in ways that met their needs.

Right Care:

Provider needed to review staff organisation and how staff’s training needs and skills were managed in order to meet some people’s specific needs.

The provider did not always ensure that actions were consistently taken to reduce assessed risks to people's personal safety. Not all staff had the right knowledge to encourage and enable people to take positive risks.

People received kind and compassionate care. Staff protected and respected people’s privacy and dignity. They understood and responded to their individual needs.

Staff understood how to protect people from poor care and abuse. The service worked with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.

People could communicate with staff and understand information given to them because staff supported them consistently and understood their individual communication needs. Staff spoke to people politely giving them time to respond and express their wishes.

People’s care, treatment and support plans reflected their range of needs and this promoted their well-being and enjoyment of life.

Right Culture:

We found the provider did not ensure we were notified of reportable events within a reasonable time frame.

The provider did not always follow their quality assurance policy effectively so they could assess, monitor and mitigate any risks relating to the health, safety and welfare of people using services, the service and others.

The provider did not consistently maintain accurate and complete records relating to person’s care and service management.

The provider did not always follow and kept a copy of all the actions taken as required in the duty of candour regulation when a notifiable safety incident occurred.

Staff knew and understood people well and were responsive, supporting their aspirations to live a quality life of their choosing.

People and those important to them were involved in planning their care. Staff valued and acted upon people’s views.

Staff turnover was stable, which supported people to receive more consistent care from staff who knew them well. People were supported by staff who understood their different range of needs or sensitivities.

The service enabled people and those important to them to work with staff to help improve the service. The home manager and staff were working together to ensure the risks of a closed culture were minimised so that people received support based on transparency, respect and positive culture in 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 inadequate (published 18 May 2022) and there were multiple breaches of regulations. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found some improvements had been made. We also found the provider remained in breach of some of the regulations.

At our last inspection we recommended the provider seek advice from a reputable source about end of life care planning. At this inspection we found the provider was working to review this aspect of support.

This service has been in Special Measures since 17 May 2022. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This inspection was prompted due to the previous rating and to follow up on enforcement action.

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.

Enforcement and Recommendations

We have identified breaches in relation to quality assurance and record keeping; risk management; notification of incidents; management of medicines; staff recruitment at this inspection. We have made recommendations about assessing, reviewing and recording mental capacity; ongoing staff training monitoring and to reflect the latest best practice guidelines; staff and senior staff deployment; management and record keeping of activities for people; management of records for duty of candour requirements. Please see the action we have told the provider to take at the end of this report.

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.