Penley Grange

Updated 6 January 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 Care Act 2014.

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

Two Inspectors, a member of the CQC medicines team and an Expert by Experience carried out the inspection. 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 Grange 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 Grange 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

The service’s registered manager was no longer in post at the time of our inspection, and was not involved in the inspection process. Where a manager is registered with the Care Quality Commission, this means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

This inspection was unannounced.

What we did before inspection

We reviewed information we had received about the service in the last 12 months. Partner agencies were undertaking regular monitoring visits to services operated by the provider, due to concerns recently identified in relation to the provider’s adjoined care home. We reviewed the feedback from professionals following these visits. We also reviewed an action plan which had been shared by the provider.

We used 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.

This information helps support our inspections. We used all of this information to plan our inspection.

During the inspection

We communicated with or observed five people who used the service and five relatives about their experience of the care provided. Where people were unable to speak with us, we spent time observing people’s body language, facial expressions and vocalisations, to help us understand their experiences of using the service.

We spoke with 19 members of staff including 12 support workers, the acting team leader, the on-site care consultant, the director, three regular agency staff and the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

We reviewed a range of records. This included five people’s care records and five people’s medication records. We looked at five staff files in relation to recruitment and a folder of collated staff team supervision records. A variety of records relating to the management of the service were reviewed, including files relating to compliments and complaints, accidents and incidents, safeguarding, staff training, minutes of staff and resident meetings, audits, staff handover records, and evidence of COVID-19 testing.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at policies and procedures. We requested additional evidence from the nominated individual, including feedback about the calculation of staffing hours. We received email feedback from several professionals including

Updated 6 January 2023

About the service

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.