This inspection took place on 18 and 19 September 2018. It was an unannounced visit to the service.

We previously inspected the service on the 10 and 11 August 2017. The service was rated Requires Improvement at the time. At that inspection we found breaches of the Regulations of the Health and Social Care Act 2008. We found people were not always protected from fire as staff did not know how to support people in the event of a fire. Staff were not always supported in line with provider’s expectations. We asked the provider to complete an action plan to show what they would do and by when to improve the key questions, Safe and Well-Led to at least good. At this inspection we found ongoing concerns about people’s safety due to a lack of action by the provider to rectify faults in fire doors and a lack of information readily available for staff on how to support people in the event of a fire. Identified actions from a water safety risk assessment had not been completed in a timely manner.

Pennefather Court 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.

The care home is located in a residential area in the market town of Aylesbury. Accommodation comprised of individual bedrooms, two dining areas and a small lounge. People had access to a garden area which was being improved to provide more level access.

The service did not have a registered manager in post on the two days of the inspection. 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. However, within the same week of the inspection the manager in post had an interview with us to become the registered manager. We received confirmation following the inspection the manager had been successful at the interview and is now the registered manager. We have referred to the manager in post at the time of our visit to the service as the registered manager as the inspection process was still open.

We received mixed feedback about the risks associated with fire and if they had been managed appropriately. We have made a recommendation about this in the report.

People gave us positive feedback about their experience about living at the home. Comments included “Its more relaxed now, we get on together,” “They [Staff] have got time for you, everyone is so kind” and “The staff are excellent, very kind and caring.”

People were supported by staff who had been recruited safely. Staff were provided with training to ensure they had the right skills and experience to support people.

People were supported by staff who had developed a kind, compassionate and caring relationship with them. We observed positive interactions between people and staff, with lots of laughter and smiles.

People told us they had opportunities to undertake meaningful activities, both within the home and the local community. Each person had a one to one session each week with a member of staff.

People told us the registered manager and deputy manager worked well together and staff told us they felt valued and listened to.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. Staff supported people to be involved in decisions about their care and support.

This inspection took place on 10 and 11 August 2017. It was an unannounced visit to the service.

Pennefather Court is a care home for adults who have physical disabilities. It is registered to provide accommodation and personal care for 16 people. At the time of our inspection 15 people lived at Pennefather Court.

We previously inspected the service on 28 June 2016 and 1July 2016. At that inspection we found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. People were not always protected from risks associated with the environment. We found light fittings broken and electrical wires exposed. At this inspection we found improvements had been made to the environment.

At the previous inspection we found staff did not have information about what support two people needed in the event of a fire. At this inspection we found up-to-date information was available for staff to follow in an emergency.

At the previous inspection we found staff did not always follow incident reporting guidance when people had accidents outside of the home. At this inspection we found staff did complete incident forms for events which occurred from the home however we found a continued breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Risk assessments were not always updated to reflect risks posed to people in particular the risk of choking. Records relating to risks were not always updated to reflect the current risks, and staff were unaware of the new guidance. One person told us they had fallen and staff had assisted them up. However there were no records about the event. Staff had failed to complete or report a fall in the home. On the first day of the inspection we found the sluice room, chemical cupboard and laundry room to be open and people had free access to hazardous products.

At the previous inspection we found breaches of the Care Quality Commission (Registration) Regulations 2009. The registered manager did not inform us of events when it was legally required to do so. We issued the provider with a requirement notice to improve. The provider sent us an action plan which outlined what changes the service had planned to be compliant. At this inspection we noted all reportable events had been notified to us. We are satisfied the requirement notice has been met.

The service had 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.

The registered manager was supported by the provider’s quality assurance officer to monitor the service and help drive improvements, however, the quality assurance systems in place did not always identify areas which required improvement. We have made a recommendation about this in the report.

People told us they felt safe within the home, and had confidence in the staff team to deliver safe care. People told us they knew who to speak with in the event of a concern being raised.

People were supported with their prescribed medicine by staff who had received training. The service was working with the Clinical Commissioning Group (CCG) pharmacist on improving medicine management within the home.

The service operated safe recruitment processes to ensure staff had the right skills and attributes. Post-employment staff received regular monitoring and support to ensure they were providing safe care. The staff team meet regularly to discuss how they could improve the service

People were treated with privacy and dignity. People were encouraged to be as independent as possible. People told us how they enjoyed activities inside and outside of the home. One person told us how they were going on holiday to Blackpool and

This inspection took place on 28 June and 01 July 2016. It was an unannounced visit to the service.

We previously inspected the service on 01 January 2014. The service was meeting the requirements of the regulations at that time.

Pennefather Court is a care home for adults who have physical disabilities. It is registered to provide accommodation and personal care for 16 people. At the time of our inspection 15 people lived at Pennefather Court.

Pennefather Court is located in a residential area, a short walk away from the market town of Aylesbury. People told us they were pleased they could go to the local town centre as it was so close.

The service had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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.

There is a requirement for providers to inform CQC when specific events happen. We call these notifications One event, for example, is when abuse or alleged abuse had occurred. When we checked if we had received all the required notifications we and found we had not. The registered manager had not reported to the CQC or the local safeguarding authority one incident which should have been reported to both.

Repairs within the home were not always completed in a timely manner. One light fitted was broken leaving electrical wires exposed. Staff told us it had been like that for two weeks.

There were processes and procedures to report accidents and incidents. However staff told us about one event when someone had fallen. We found no record this had been reported. This meant the registered manager could not monitor trends to reduce future incidents.

The registered manager told us they were aware of their role and responsibilities. However we found two people did not have any information about how staff should support them in an emergency. This meant they could have been placed at harm in the event of a fire.

We received positive feedback about the service. Comments included. “This place is outstanding, the staff are really helpful, and they (staff) go out of their way to make sure we are ok.” A relative told us “Staff are brilliant; they always make us feel welcome.”

People told us they felt safe at the service. Comments included “ I feel very safe hear, the staff are always around,” and “I feel safe, if I did not, I would talk to staff, or if it involved a senior member of staff I would go to social services.”

Staff had been selected following robust recruitment processes to ensure they had the right skills and attributes to work with people. Some staff had worked in the service many years and had developed good working relationship with people who lived at the home.

People had access to a wide variety of activities. These were based on what people wanted to do. For instance, two people attended a day centre and one person went to a drama group. Feedback was regularly sought from people who lived at the home. Another person liked to go on holidays and one other person like to sew. We observed another person making a rug.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found breaches of the Care Quality Commission (Registration) Regulations 2009. You can see what action we told the provider to take at the back of the full version of the report.