The inspection was carried out on 10 and 21 August 2018. The first day of the inspection was unannounced.

Penkett Lodge is a care home. 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

Penkett Lodge is registered to provide support for up to 27 people. At the time of our inspection 23 people were living there. The registered manager explained that the home has some double rooms, these are only used by people who ask to share a room.

The home has a registered manager. 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.

At our last inspection of the home in March 2017 published in May 2017 the service was rated requires improvement overall. We found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in respect of Regulations 11, 12 and 17.

This was because day to day care practices did not always enable people's consent and freedom of choice to be respected. The moving and handling techniques used by staff in support of people's mobility was not always safe and did not always mitigate risks to their health, safety and welfare, and medicines were not always managed or administered in safe way. We had also found that some of the provider's quality monitoring systems were ineffective in identifying and addressing inappropriate care and unsafe medication practices.

After that inspection the provider wrote to us to say what they would do to meet their legal requirements. At this inspection we identified that improvements had been made with regards to regulation 12, safe care and treatment and regulation 11, need for consent. During this inspection we found breaches in relation to Regulations 10, and a remaining breach to regulation 17 of the Health and Social Care Act 2008 (Regulated Activities). Regulations 2014.

You can see what action we told the provider to take at the back of the full version of the report.

Staff did not always treat people with dignity and respect. Some of the language staff used in front of people, such as “feed her”, was not respectful. We also found that the way in which the building was maintained and looked after was not always safe or dignified. For example, we found that towels and face clothes were faded and fraying, people’s bedrooms and communal areas were not always well looked after. This included curtains that were missing hooks, chipped and peeling wallpaper and paint and stained table mats and dirty condiments.

On the first day of our inspection we found that the call bell system was not consistently working correctly and that an outside door had not had a keypad fitted although this had been identified as required by the registered manager.

Systems were in place for checking the quality of the service provided. However, these were not effective at identifying and addressing improvements needed within the service. This included improvements to the environment, repairs and ensuring people were always treated with dignity.

Systems were in place for safeguarding people from the risk of abuse and reporting any concerns that arose. People said they felt safe living there and staff knew what action to take if they felt people were at risk of abuse. A system was in place for raising concerns or complaints and people living at the home and their relatives told us they would feel confident to raise a concern.

People’s medication was safely managed and they received their medicines as prescribed. Staff provided people with the support they needed to manage their physical and mental health care needs

This inspection took place on the 16 March 2017 and was unannounced,

Penkett Lodge provides personal care and accommodation for up to 27 people. Nursing care is not provided. The home is a detached four storey building in Wallasey, Wirral. A small car park and garden are available within the grounds. There are twenty one single bedrooms and three shared bedrooms with communal bathrooms on each floor. Some of the rooms are en-suite. A passenger lift enables access to bedrooms located on upper floors and specialised bathing facilities are available. On the ground floor, there are two communal lounges and a dining room for people to use. At the time of our visit, there were 26 people who lived at the home.

The home had a registered manager. 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’. The registered manager had been employed at the home for over five years.

During this inspection, we found breaches of Regulations 11, 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches related to respecting people’s right to choose and safe medication management. You can see what action we told the provider to take at the back of the full version of this report.

We looked at the care files belonging to four people. We saw that people’s capacity was assessed where their ability to make informed decisions was in question. Where people were assessed as lacking capacity, a best interest decision process had been undertaken before any decisions were made on the person’s behalf. It was clear from looking at people’s records that the manager had considered the Mental Capacity Act 2005 (MCA) when assessing people’s capacity but at times the way people’s capacity was assessed did not comply in full with the MCA legislation. We spoke with the registered manager about this.

During the visit, we saw that one person’s ability to decide for themselves where they wanted to spend their time was not always respected or followed. This meant that this person’s liberty was restricted. There was a risk that this restriction was unlawful. We spoke with the registered manager about this. They told us that staff did not act on the person’s wishes to go to their room as they were worried they may have a fall. They acknowledged that the person’s right to choose where they spent their time should have been respected and facilitated by the staff team and the risks managed appropriately.

We observed a medication round. We saw that staff did not always observe people taking their medication before they signed the person’s medication administration record. This meant that staff could not be certain that the person had actually taken it before they signed to say that they did. We found that some of the eye drop medication at the home was not stored safely and some of the medication had exceeded it expiry date but was still in use. This placed people at risk of harm.

We saw two incidences staff supported people’s moving and handling needs in an inappropriate way. On both occasions the staff members supported people’s weight to transfer to or from a seat using an underarm lift. This type of lifts can cause physical injury to both the person requiring support and the staff member. We spoke with the manager about this.

People’s care plans described their individual needs. People’s wishes and preferences in the delivery of care were documented. There was clear guidance for staff to follow to ensure that people’s needs were met and their risks managed. We saw that people received care from a range of health and social professionals. For example, doctors, dentists, district nurses, occupational therapy,

We carried out an unannounced comprehensive inspection of this service on 17 and 20 April 2015. During this visit a breach of legal requirements was found. We found the provider was failing to provide safe care and treatment. We asked the provider to take appropriate action to ensure improvements were made to the safety of the care provided. We issued them with a warning notice with a set deadline for meeting this legal requirement in order to ensure a swift response to any risks.

We also found a breach of legal requirements with regards to ensuring people legally consented to the care they received and the way in which the provider monitored and managed the quality and safety of the service. We issued the provider with requirement actions. Requirement actions require the provider to make the necessary improvements to ensure legal requirements are met, within a timescale they agree is achievable, with The Commission.

We undertook this comprehensive inspection on the 23 October 2015. During this visit we followed up the breaches identified at the April inspection We found the provider had taken appropriate action in relation to the warning notice and made the required improvements to meet all of their legal requirements.

This report only covers our findings in relation to these topics. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘ Penkett Lodge’ on our website at www.cqc.org.uk’

Penkett Lodge provides personal care and accommodation for up to 27 people. Nursing care is not provided. The home is a detached four storey building in Wallasey, Wirral. A small car park and garden are available within the grounds. There are twenty one single bedrooms and three shared bedrooms with communal bathrooms on each floor. Some of the rooms are en-suite. A passenger lift enables access to bedrooms located on upper floors for people with mobility issues and specialised bathing facilities are available. On the ground floor, there are two communal lounges and a dining room for people to use.

A registered manager was in post at the time of our visit. 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.

At our last inspection in April 2015, we found safeguarding incidents were not always appropriately recognised or reported to the relevant authorities. People’s needs and risks in relation to skin integrity, choking and challenging behaviour were not always adequately risk assessed or managed. The storage of some medicines was unsecure and the way in which medication was administered was not safe. The premises were not entirely safe and suitable for purpose and the systems the provider had in place to monitor the quality and safety of the service were found to be ineffective.

During this visit, we reviewed a sample of the provider’s safeguarding and complaint records. All of the records we looked at, showed that an appropriate investigation had been undertaken, the relevant authorities notified and comprehensive records maintained. This meant there was a clear audit trail of how safeguarding incidents and complaints were managed. Records showed the manager had a clear understanding of the action to take in the event of a safeguarding allegation or complaint being made.

We looked at three people’s care records to check suitable management plans were now in place for pressure sores, swallowing difficulties and challenging behaviour. We saw that this was the case. People’s needs and care was clearly identified. Risks in relation to pressure sores, choking and challenging behaviour were assessed and care plans contained sufficient information to enable staff to care for people safely.

On the day of our inspection, we saw that mediation was stored securely. People’s medication records had been completed appropriately with regards to the time of administration and signed by the staff member responsible for administering the medication.

Improvements to the premises identified by Environmental Health had been completed. As a result, the provider’s food hygiene rating had been re-evaluated and they had been awarded a rating of five (very good). Actions identified by the NHS Infection Control team had been completed. This included the installation of modern sluice facilities. The home’s electrical repairs had been undertaken and the electrical system was now certified by an external contractor as safe. The outside garden area containing nine planters for people to plant their own vegetables and flowers in, had been repaired and looked a safe and pleasant area for people to enjoy.

The manager had introduced processes and procedures in accordance with the Mental Capacity Act 2005 and Deprivations of Liberty (DoLS) 2009 which protected people’s legal right to consent to the care they received. We saw that best interest considerations had been undertaken prior to any decisions being made to deprive a person of their liberty. Care plans had been improved with more in depth person centred information and personal life history information which enabled staff to gain a better understanding of the person they cared for. This is especially important for people who live with dementia type conditions.

A new maintenance person had been employed and we saw from the maintenance records that issues were identified and addressed promptly. Health and safety audits were also now in place to identify and mitigate risks to people’s health, safety and welfare. This showed that the provider had systems in to ensure the premises remained in good repair and suitable for purpose.

Medication management checks were improved and provided an audit trail of how medicines were received, administered and managed at the home. This meant the manager was able to assess if the management of medication at the home was safe.

Accidents and incident analyses were undertaken and any trends in the way they occurred used to improve the quality and safety of the service and the provider now met with the manager on a weekly basis to support them in their management role.  At this inspection, we found the manager had proactively addressed all of the concerns identified at the last visit. 

At the last inspection in May 2013 we had minor concerns about the provider’s maintenance arrangements in relation to equipment used at the home, the number of staff on duty in the morning and the home’s record keeping.

We discussed our concerns with both the manager and the provider during our visit in May. An action plan was put in place by the home outlining the improvements they intended to make. During this visit we checked the home’s action plan had been achieved and compliance with the regulations now reached.

As part of our visit, we reviewed the home’s maintenance records and found that suitable systems to check the equipment used by people living at the home was in good repair, free from defect and safe for use, were now in place.

We saw that staffing levels at the home between 8-10a.m. in the morning and 5-10p.m. at night had been increased by one staff member. We observed staff caring for people in the morning and noted that the extra staffing had a positive effect on the availability of staff and their ability to be respond to people’s needs in a timely and responsive manner.

We examined the care records for three people who lived at the home and found them to accurately and appropriately reflect people’s needs. We also reviewed the records maintained in relation to the staff rota and found they clearly identified which staff member was on duty on any given day.

We found the home had undertaken all the actions outlined in their action plan and had sufficiently improved in all areas of concern previously identified.

Some people at the home had mental health issues and were unable to tell us about their experience of living at the home. We spoke to three people and one relative. They told us the care was very good.

We looked at three care records. We found they were personalised to the individual and gave staff simple instructions on how to care for each person. All care plans were regularly reviewed and daily written records showed people had received care and support.

We saw staff spoke to people kindly and with familiarity. We observed however that there were insufficient staff on duty in the morning to tend to people's needs in a timely and responsive manner. This meant there was a risk of people's needs not being met.

Staff we spoke to knew how to identify and respond to signs of abuse appropriately. A safeguarding procedure was in place and staff had regular training in safeguarding.

We reviewed the provider's arrangements for the safe use of equipment. We found the provider did not have a suitable system in place to check that equipment remained free from defect and safe for use.

Due to concerns raised at our last visit, we looked at the quality and security of records. Records were now held securely and complaints/compliments documented appropriately. There were inconsistencies however in the updating of care plans and the staff rota. This meant people's needs were not fully reflected and that arrangements for staff cover were unclear.

We talked with 7 people living at the home. They told us they were happy at the home and that the care was good. They said:

"I am treated very well and my needs are tended to”

“I have no complaints about anything, I am very happy here"

"The staff are very good"

People told us they were involved in their care and able to make choices in every day living activities such as food choices, meal times and the level of assistance needed with personal care.

We observed that people were well cared for and treated with dignity and respect. People’s needs were assessed and reviewed. We found care records contained relevant information in relation to personal details, individual needs and preferences. Care plans and risk assessments were in place and individualised. However review records were not accurate and risk assessments/care plans were not updated in line with changes in people's needs. This meant that people using the service could be at risk of not having their needs met. Staff completed daily evaluations sheets which showed that people received the care they needed.

Care records were not stored safely which posed a risk to confidentiality. Care records were kept in an unlocked office accessible to all care staff, other healthcare professionals and visitors to the home.

Staff were appropriately trained, supported and appraised to care for people’s needs. They demonstrated an awareness and understanding of how to protect people from abuse.

An expert by experience joined us on our visit and spent the time talking with people who lived at the home and relatives who were visiting them. She observed that two people were sitting in the dining room doing crosswords. They told her that they liked sitting there and this demonstrated the relaxed and homely environment. All of the people she spoke with said how much they look forward to the daily afternoon activities done by the activities co-ordinator. One person pointed out the area designated in the garden where vegetables are planted. People interested in gardening are given assistance to plant vegetables.

One person said how he appreciates going to the local pub once a week where he can meet up with friends: “it make me feel part of the community”. Other people are taken out by relatives. There is a quiet lounge and copies of the local newspaper available.

People said that the meals are very nice and they always had choices. A member of staff was noting down each person’s choice of meal for lunchtime. Drinks were available in the bedrooms and a bowl of fresh fruit was on each table in the dining room. People can choose when they get up for breakfast. One person said she prefers to have breakfast in her room because she likes to stay in her room until late morning.

One of the relatives said that meals are always beautifully presented and her mother always commented on how tasty the meals are, and added that on one occasion, due to circumstances, she was offered a meal. She said “it could not have been better, it was delicious”.

One relative who spoke with the expert by experience said that he is very satisfied with the care. Another said that staff are very approachable but information is not readily given, you have to ask for it.

We contacted the district nurses who provide support for people living at Penkett Lodge and they told us that they did not have any concerns about the care of people living there.

The expert by experience observed that staff were very polite and respectful in their dealings with residents. One person told her “Staff are very nice and they look after you”.

Penkett Lodge provides personal care and accommodation for up to 27 people. Nursing care is not provided. The home is a detached four storey building in Wallasey, Wirral. A small car park and garden are available within the grounds. There are twenty one single bedrooms and three shared bedrooms with communal bathrooms on each floor. Some of the rooms are en-suite. A passenger lift enables access to bedrooms located on upper floors for people with mobility issues and specialised bathing facilities are available. On the ground floor, there are two communal lounges and a dining room for people to use.

The home had a registered manager. 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 who lived at the home said they were happy there and were well looked after. They said they were supported to maintain their independence and treated with dignity and respect. People had access to sufficient quantities of nutritious food and drink and were given suitable menu choices at each mealtime.

During our visit, we observed that staff treated people kindly and supported them at their own pace. People looked relaxed and comfortable with staff. From our observations it was clear that staff knew people well and had the skills and knowledge to care for them. An activities co-ordinator was employed at the home five afternoons a week and provided a range of activities to occupy and interest people.

We observed the home’s morning medication round. We saw that it was constantly interrupted by staff, the telephone and deliveries to the home. This meant there was an increased risk of mistakes being made and a delay to people receiving their medication on time. Records relating to some boxed medications were inaccurate. People’s prescribed creams were not always stored securely. This was a breach of Regulation 12 of the Health and Social Care Act 2014 Regulations.

People’s feedback on staffing levels was mixed. Some people said that at times the number of staff on duty required improvement. We observed that staffing levels during the morning and afternoon medication round required review and that staff were often too busy tending to people’s personal needs and other tasks to have time to just sit and chat to people. Staff were recruited safely and received regular training and support in the workplace.

People told us they felt safe at the home and they had no worries or concerns. The home had a safeguarding procedure and staff received safeguarding training but they did not demonstrate a full understanding of safeguarding when asked. They did however demonstrate a positive attitude to people’s welfare. We reviewed the provider’s safeguarding records. We found that although issues raised had been investigated and responded to by the manager, they had not always been reported to the Care Quality Commission in accordance with Regulation 18 of the Care Quality Commission (Registration) Regulations 2009.  In addition, some of the complaint records we looked at, although fully investigated, where of a safeguarding nature.  They had not however been treated as a potential safeguarding matter or reported to the Care Quality Commission.

We reviewed three care records. Some risks associated with people’s personal care and welfare were assessed and managed however two people with skin integrity issues and a physical change in one person’s ability to safely eat and drink had not been risk assessed and safely managed. People’s challenging behaviours had not been assessed but staff lacked adequate guidance on how to manage them. These incidences were a breach of Regulation 12 of the Health and Social Care Act 2014 Regulations as people’s plans of care did not fully meet or manage their needs and risks.

Where people had mental health issues, their care plans lacked adequate information on how this impacted on their day to day lives and decision making. There was little guidance for staff on how to support people’s emotional needs. This was a breach of Regulation 11 of the Health and Social Care Act 2014 Regulations as people’s right to consent had not been considered in accordance with the Mental Capacity Act 2009.

People were provided with information about the service and life at the home. There was a complaints procedure in place and the manager had responded appropriately to complaints made.

Equipment was properly serviced and maintained but the premises were not entirely suitable for purpose. Improvements were required to meet Environmental Health legislation and good infection control standards and the provider's electrical installation had been inspected as unsafe in June 2014.  There was no evidence that the provider had taken appropriate and timely action to protect people for the risks of unsafe and unsuitable premises.  These incidences were a breach of Regulation 12 of the Health and Social Care Act 2014 Regulations.

There were some quality assurance systems in place to assess the quality and safety of the service and to obtain people’s views but, improvements were required to ensure that they were sufficient and effective. There was little evidence that the provider monitored the quality of the service to ensure it was safe or that they provided appropriate support to the manager. This was a breach of Regulation 17 of the Health and Social Care Act 2014 Regulations as the provider failed to have effective systems in place to assess, monitor and mitigate the risks to people’s health, safety and welfare.