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

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 serv

Penhellis Nursing Home is a care home that provides nursing care for up to 26 older people. On the day of the inspection there were 24 people using the service.

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 and associated Regulations about how the service is run.

We carried out this unannounced inspection of Penhellis Nursing Home on 20 July 2015. At this visit we checked what action the provider had taken in relation to concerns raised at our last inspection on 5 November 2014. At that time we found people living with dementia, were not supported with information to help orientate them to day and date. Menus were not available to help remind people of the lunch choices. There were no records of when people and their families had been involved in the planning of their care. People’s consent had not been sought for photographs being displayed in their care records and care records were not kept securely. The front door was locked and the code was not available for people who had the ability to manage their own safety. People, visitors and staff told us they did not find the registered manager approachable.

At this inspection we found the service had purchased a clock to display the time and date in the main lounge to help orientate people to the day and time. Menus were on display and staff reminded people at lunchtime of the meals they had chosen. This supported the needs of people living with dementia.

People were asked to sign to give their consent to their care plans and for photographs being displayed in their care records. People’s care records were stored in a room fitted with a coded lock and this meant people’s information was kept securely.

The service had made changes to the environment to enable people to have access to appropriate outdoor areas and use the front door independently. This included the refurbishment of a courtyard area, the addition of a sun lounge in the garden and a new door entry system.

People, visitors and staff told us they found the registered manager supportive and approachable. Staff said, “[registered manager’s name] has always been approachable and supportive with any issues raised, excellent listener” and “[registered manager’s name] is very supportive towards all staff”.

People told us they felt safe living at Penhellis Nursing Home and with the staff who supported them. People told us, “I feel safe” and “They [staff] have a nice attitude with me”. A relative said, “I definitely wouldn’t want dad to be anywhere else”. A healthcare professional told us, “Have always found staff to be knowledgeable and caring about the residents”.

Staff interacted with people in a caring way, appropriate to people’s individual needs. People told us, “You don’t get treated as an old person”, “They [staff] look after you so well”. A relative said, “Yes, the care is very good. I wouldn’t put my dad anywhere else. We looked at a few homes but chose this one because of the atmosphere”.

Staff had received training in how to recognise and report abuse. All were clear about how to report any concerns and were confident that any allegations made would be fully investigated to help ensure people were protected.

There were good opportunities for staff to receive on-going training and for obtaining additional qualifications. Recruitment processes were robust and appropriate pre-employment checks had been completed to help ensure people’s safety. There were enough skilled and experienced staff to help ensure the safety of people who used the service.

People were supported to maintain a balanced diet appropriate to their dietary needs and preferences. People were able to choose where they wanted to eat their meals, in either a lounge, dining room or their bedroom. People were seen to enjoy their meals on the day of our visit.

Staff supported people to be involved in and make decisions about their daily lives. Where people did not have the capacity to make certain decisions the service acted in accordance with legal requirements under the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards.

People and their families were given information about how to complain and people told us they knew how to complain. There was a management structure in the home which provided clear lines of responsibility and accountability. There were effective quality assurance systems in place to ensure that any areas for improvement were identified and addressed.

We inspected Penhellis Nursing Home on 5 November 2014, the inspection was unannounced. This was a comprehensive inspection which was brought forward after we received information of concern. We reviewed the information held by the Care Quality Commission about this service prior to the inspection. We last inspected Penhellis on 10 March 2014. At that time there were no concerns.

Penhellis is a care home for older people who require nursing care. It provides accommodation over two floors for up to 26 people. At the time of the inspection there were 24 people living at the service.

There was a registered manager at 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 and associated Regulations about how the service is run.

Some people, visitors and staff did not find the registered manager approachable saying, “ On occasions I have faced a brick wall when I have spoken to the manager” and “She is not very empathetic.” The registered manager had quality assurance and monitoring systems in place to manage the building and the business. However, people, staff and visitors reported the registered manager did not manage people well.

Staff working at the home understood the needs of people they supported. However, it was not recorded when people and their families were involved in the planning of their own care and their consent was not sought to their photographs being openly displayed on their care records. Care records were not kept securely.

People were not supported with information to help orientate them to day and date and prompt them to recall what was being provided at meal times. There was no calendar or board showing what day it was and people were not aware what was being offered for meals as there was no menu to prompt them. There was outside space for people to enjoy. This was not secure and staff told us some people required support when outside in the garden to ensure their safety. People could not leave by the front door independently as it was locked with a coded key pad. The code was not available for people who had the ability to manage their own safety, should they wish to leave independently. This did not respect and consider people’s right to make independent choices for themselves.

People were supported in a safe way. There were sufficient numbers of well trained and competent staff at the home to meet people’s needs. Staff were aware of how to raise any concerns they may have. People received their medicines at the prescribed times. People had good access to healthcare professionals when needed. There was a programme of activities available for people should they choose to take part.

Visitors and family reported, “Yes, my (relative) loves it here, (they) enjoy the surroundings and enjoy sitting in the garden on nice days. I wouldn’t hesitate to talk to staff if there was a problem, I would speak to the relevant staff. My (relative) does receive (their) medication on time and I discuss any changes with the nursing staff.” We saw people were happy living at the home. The atmosphere was friendly and staff and people living at the home were relaxed in each other’s company. People told us, “It is really lovely being here, its like a hotel,” and “The staff are all excellent.”

The inside of the building was accessible, well maintained and comfortable. There were a choice of places for people to spend time with visitors, taking part in activities, or spending time on their own.

During our inspection we observed people looked well cared for and their needs were met quickly and appropriately. People who lived at the service and their relatives were complimentary about the care and support they received from staff who they felt were knowledgeable and competent to meet their individual needs. People told us, “Staff are wonderful, I am well looked after, I have no complaints,” and This is the best home I’ve seen, good appearance, no smell and very welcoming.”

Staff were appropriately trained and skilled to ensure the care provided to people was safe and effective to meet their needs. Staff did not have a good understanding of the Deprivation of Liberty Safeguards (DoLS).

The  had developed positive contacts with other professionals who ensured effective care delivery for people whenever they needed or wanted it.

We found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of the report.

We carried out a responsive inspection of Penhellis Nursing Home because the Care Quality Commission had received anonymous information of concern regarding the care and welfare of people. The concerns related to the alleged abuse of one person, the lack of dignity regarding continence management and the lack of response when supporting people’s tissue viability. We were also told that when certain staff were on duty some people remained in bed and were not involved socially with the rest of the home.

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.

During our inspection we spoke with the registered manager, registered provider, three members of staff and five people who were living at the home. People told us the home was “beautiful” and the staff were “nice”.

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.

People were very complimentary about the staff saying that they are “very helpful” and “lovely”. We heard the staff talking with people in a calm and respectable manner

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.