Archived: Pennfields Court Nursing Home

We carried out this review of compliance to look at all the information we had received since we told the provider where they needed to improve. We inspected the service in March 2012 to check the improvements that the provider had made. One of the inspectors that visited was a pharmacist.

People that live at Pennfields Court had difficulty expressing their views due to their mental health. We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with

We also spoke to a visitor, four staff and the interim manager during our time at the home.

We saw that the provider has commenced discussion with people's relatives as to how to involve them more with the care they received. We saw sight of minutes from a relatives' meeting in March 2012. We looked at people's records and these did not reflect people's involvement, although one visitor we spoke to said that they were involved with the care of the person they represented.

We saw that the provider had made some progress in removing bolts from bedroom doors, and fitting more appropriate privacy locks that could be opened from inside the room. We saw that a few bolts remained on one bedroom and bathroom doors.

From observation of staff assisting people with a meal we saw that they took time, and involved people even though there was limited response. They told people what they were doing, when they were going to give them food and also offered reassurance, this sometimes through appropriate contact, such as touching their arm. We also observed staff talked to people when they were assisting them with transfers, telling them what was happening so they knew what to expect. A relative of a person who lived at the home told us that the staff ensured people's health needs were met, and were good at encouraging people to have a good diet.

We looked at three people's care plans and other records about people and saw that these were not written in a way that told staff how they should met people's needs. We found no care plans for two people that were stated in assessments to be epileptic, this meaning staff may not know what signs to look out for or what to do if they had a seizure. We saw that one person used bedrails yet the risk assessment was blank meaning any dangers presented by the use of this equipment, and how these were to be minimised had not been considered. In addition the person's moving and handling assessment was not specific as to type of lifting sling staff should have used to transfer this person safely.

We observed staff assisting a person to transfer to a seat in the lounge, during which they became unable to weight bear. Staff stopped the person from falling by using underarm lifting techniques which have the potential to cause harm. There was conflicting information about how staff were to assist this person with transfers in care records and staff we spoke to were unclear as to how they should assist them, although they recognised that their needs had changed recently. Staff we spoke to understood that underarm lifting should not be used.

We looked at recent incident reports and found one record where a person had been noted to be lying face down on their bed. The staff identified that there was a risk of suffocation and that a care plan should be developed to ensure this did not happen. This care plan was not in place.

When we last visited the home there was concerns about how people were protected from one individual as there were many incidents where they put others at risk. This person has now left the home and a relative said there were no concerns to people's safety as a result. They also told us that they knew who to speak to should they have any concerns.

We observed staff practice promoted good infection control with use of appropriate protective wear. We saw staff washing their hands between care tasks. We found no evidence of unattended spillages or unpleasant odours in the home. We did find that some areas of the home, such as the underside of dining chairs still carried some detritus, as we identified in November 2011.

We looked at the home's systems for the management of medicines and found that people are not fully protected against the risks associated with the unsafe use and management of these.

We saw that the provider has addressed concerns in respect of defective fire door closers and ensured that fire escape routes are accessible. The building was in the process of redecoration when we visited and some of the signage for bathrooms and toilets has improved.

We spoke to one relative who said that they were happy with the staff at the home. They also said that there was use of a small number of agency staff, which was confirmed by staff who told us that the same agency staff were usually booked for more than one working shift. This helped with the consistency of care, ensuring that where possible people knew the agency staff.

We saw minutes of the last relatives' meeting in March 2012 and they showed numerous issues in respect of the home's progress and development were shared with relatives, including outcomes from our inspections.

We saw some evidence that the provider is identifying some areas where improvement is needed and there had been improvements we saw that had reduced the risk presented to people living at the home. There was still significant concerns in respect of people's care, welfare and medication administration that the service had not identified. We therefore found that the service did not have an effective quality assurance programme in place to ensure the safety of the people using the service.

We observed staff attending to people in a manner that promoted their dignity and privacy.

Inadequate privacy locks and screening at windows could compromise people's right to privacy.

Care plans told staff what people's care needs are but failed to inform staff how to meet them.

We observed staff attending to people's needs in a sensitive manner.

We spoke with two visiting relatives who said they were generally happy with the care provided to people. However, they had both witnessed incidents between staff and people who use the service which they considered to be unacceptable practice. One relative had reported this to senior staff.

Records of incidents were maintained and showed one person was being slapped or hit on a regular basis by another person living at the home. We found that these incidents had not been referred to the multi-agency procedures for investigation.

One visiting relative raised concerns about the standard of hygiene within the home.

We observed that the home was unclean in some areas and there were unpleasant odours within some bedrooms.

People who use the service do not have the capacity to manage their medicines and this was done by trained nurses.

We found that medication systems and practices were unsafe.

We found the home was in need of decorating and lacked visual stimulation.

The malfunction of fire doors could compromise the safety of people in the event of a fire.

We spoke with two visiting relatives who told us that staff work well with people and that they were generally happy with the service provided.

A visiting professional said they were very pleased with the progress made by the person placed at the home since their admission.

Visiting relatives told us they had attended relatives' meetings in the past, but that these were not always at a time convenient for them to attend. One comment was made that issues raised at these meetings did not appear to be acted upon.