This unannounced inspection took place on 24, 25 and 30 April 2018.

Pennwood Lodge Nursing Home 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.

Pennwood Lodge Nursing Home provides residential and nursing care for up to 60 people living with dementia. At the time of our inspection there were 27 people living there. The home has four 15 bedded units, each with their own communal lounges, dining rooms and bathrooms. One of the units was closed and due to be refurbished. Of the other three units two accommodate people with nursing care needs. All bedrooms are for single occupancy and the majority of rooms had en-suite facilities.

We previously inspected the service in August and September 2017 and rated the service ‘Requires Improvement’ overall. We found the service did not meet the requirements of three of the regulations. Risks to people had not been sufficiently identified and action had not always been taken to reduce or mitigate risk to keep people safe from harm. Staff had not always received the support they needed to undertake their roles effectively. Systems and processes used to monitor the service had not identified these shortfalls and had not led to improved outcomes for people.

We asked the provider to complete a plan of action to show how they would make the required improvements. We also told the provider they needed to meet the regulation relating to Good Governance by 31 January 2018.

At this inspection we found improvements had been made and the service met the regulations. However, further improvements were needed before the service could be rated ‘Good’ overall. We again rated the service 'Requires Improvement' and this is the second time the provider has been rated 'Requires Improvement' overall.

People’s risks had been assessed and risk management plans were in place. We found improvements had been made to the monitoring of those people at risk of weight loss. Nurses had managed risks relating to people’s skin and wounds were treated appropriately. However, people’s wound records and behaviour support plans were not always comprehensive and completed in a timely manner. Plans were in place to complete these with support from the newly appointed mental health nurse. This was so staff and visiting professionals had access to clear guidance and up to date information about people’s care.

The provider’s quality assurance systems had resulted in improvements having been made to the service since our last inspection. These systems had been effective in ensuring the service met the required regulations. The quality monitoring of the service needed at times to be more effective to ensure when shortfalls were identified, for example in relation to people’s records, the action taken to drive improvement would always result in shortfalls being addressed promptly. The provider had recruited a new manager, clinical lead nurse and mental health nurse to support these require improvements.

There was no registered manager at the time of our inspection but the provider had recruited a new experienced manager from one of their other services. They were already working in the service and were planning to register with CQC to ensure the provider met their registration requirements. 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 prescribed medicines were stored and administered safely. We observed staff following best practice when administering people’s medicines and the medicine records were complete.

People were cared for in

This unannounced comprehensive inspection took place on 30 and 31 August and 5 September 2017.

Pennwood Lodge Nursing Home provides residential and nursing care for up to 60 people living with dementia. At the time of our inspection there were 38 people living there. The home has four 15 bedded units, each with their own communal lounges, dining rooms and bathrooms. One of the units was closed and due to be refurbished. Of the other three units, one is for people with personal care needs (residential care) and the other two are for people with nursing care needs. All bedrooms are for single occupancy and the majority of rooms had en-suite facilities.

We last inspected the service in June 2015 and we rated the service Good. At this inspection we have rated the service Requires Improvement and we will require an action plan of how and when the improvements will be made.

There was 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 were at risk of unsafe care and treatment because assessments of their needs were not always reflective of their current risks and support requirements. People's care plans did not always provide the care staff with clear guidance to follow to know how to support people safely. Care plans were not always personalised to meet people's individual needs when they were living with dementia.

Systems were in place to monitor the quality of the service and risks, however these quality assurance systems were not always effective in driving improvements. The provider had identified improvements were needed in relation to staff supervision and care planning, but timely action had not been taken and we found these areas continued to require improvement.

Medicine practices required improvements to ensure medicine records would always be completed and medicine stock kept would be sufficient to ensure people received their medicines as prescribed.

Some pressure relieving equipment was not used correctly and placed people at risk of skin damage.

People living with dementia did not always have a positive dining experience and we made a recommendation to support the provider to make improvements. People had access to healthcare professionals and their health and welfare was monitored by them.

People made most decisions and choices about their care when possible. When people did not have the capacity to make decisions staff followed the Mental Capacity Act guidance to protect them and helped people to make choices.

People were treated with kindness and respect. They told us staff were good when they supported them with their care. Staff knew how people liked to be supported. People told us they felt safe in the home. People were supported by staff who were trained and had access to training to develop their knowledge.

Some people joined in with activities provided which included ball games, musical entertainment, visits by the therapy dog, nail pampering, crafts and boards games. There was minibus and the registered manager was looking at increasing opportunities for people to access the community. People and their relative's views and concerns were taken seriously. They completed surveys and contributed in regular meetings. Staff meetings were held monthly and staff were able to contribute to the running of the home. The registered manager was approachable with relatives, staff and people and had plans to improve the service.

We found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Full information about CQC's regulatory response to any concerns found during inspections is added to reports after any representations have been concluded.

We carried out an unannounced focused inspection of this service because we had received some information of concern. We have only looked at the areas of Responsive and Well-Led as the concerns sat within these areas.

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

Pennwood Lodge Nursing Home is registered to provide residential and nursing care for up to 60 people living with dementia. At the time of our inspection there were 35 people in residence. The home has four 15 bedded units, each with their own communal lounges, dining rooms and bathrooms. However, one of the units was closed in 2015 and has remained closed since. This reduces the capacity of the home to 45. Of the other three units, one is for people with personal care needs (residential care) and the other two are for people with dementia and nursing care needs. All bedrooms were for single occupancy and the majority of rooms had en-suite facilities.

At the time of the inspection there was no registered manager in post. There has been no registered manager since November 2015 and the provider was required to have a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider. The provider had taken steps to recruit a permanent manager but not been successful. In the interim, the provider had allocated ‘turnaround managers’ to manage the service. The current turnaround manager commenced the application process to be the registered manager during our inspection visit.

At this inspection we have looked at care plans and other related care documents. We have looked at the staff rota’s for a six week period and discussed the staffing arrangements.

We found some shortfalls in the care documentation for two people. The provider took immediate action to address the issues and put measures in place to conduct spot checks and random night checks to ensure the expected standards were implemented and sustained.

Because we did not look at the procedures in place and working practices for all 35 people in residence, we have not revised our rating of the service.

The inspection was unannounced. When we last inspected the service in January 2015 we found there were four breaches of legal requirements. These were in respect of safeguarding people from abuse, consent to care and treatment, respecting and involving people and assessing and monitoring the quality and safety of service provision. We have checked during this inspection that the required improvements have been made.

Pennwood Lodge Nursing Home provides residential and nursing care for up to 60 people living with dementia. At the time of our inspection there were 35 people in residence but one person was in hospital. The home has four 15 bedded units, each with their own communal lounges, dining rooms and bathrooms. One of the units was closed and due to be refurbished. Of the other three units, one is for people with personal care needs (residential care) and the other two are for people with dementia and nursing care needs. All bedrooms were for single occupancy and the majority of rooms had en-suite facilities.

There was no registered manager in post at the service however the interim home manager had already made application to CQC to be registered and was due to be interviewed in July 2015. A permanent home manager has already been appointed but is unable to take up the post until the autumn. They will then apply for registration with CQC. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.

The manager and staff team were knowledgeable about safeguarding issues and knew what to do if there were concerns about a person’s safety. Events that had happened were reported appropriately to the local authority and the Care Quality Commission. This was a significant improvement from our last inspection when events were not being reported appropriately.

A range of risk assessments were completed for each person and appropriate management plans were in place. In addition, specific risk assessments were completed that related to the person’s care and support needs, for example, the risk of choking, or risks resulting from their behaviours.

The premises were well maintained and maintenance checks were completed on a weekly, monthly and quarterly basis. Regular servicing of all nursing equipment ensured they were maintained in good working order. Some parts of the home were shabby and there was concern expressed by relatives in respect of the delay in refurbishment works.

There have been significant changes in the staff team since the last inspection. A new ‘interim’ manager was in place and a number of new staff had already been recruited. There was an ongoing recruitment drive in place. Agency staff were sometimes used. When they were, it was usually someone familiar with the service. This ensured people were looked after by staff they knew. Staffing numbers each shift were based upon the collective needs of all the people in residence and adjusted as and when necessary.

People’s medicines were managed safely. There were procedures in place when a person who lacked the capacity to make decisions declined their medicines. This involved decisions being taken with the involvement of families, healthcare professionals and staff to decide if it was in the person’s best interests to conceal medicines in their food or drink.

All staff completed a programme of essential training to enable them to carry out their roles and responsibilities. New staff completed an induction training programme and there was a programme of refresher training for the rest of the staff. Care staff were supported to complete nationally recognised qualifications in health and social care.

People made their own daily living choices and decisions where possible. Where people lacked the capacity to make decisions, best interest decisions were recorded by those involved. Staff received training in the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) and knew how to apply this to their role. We found the home to be meeting the requirements of the Deprivation of Liberty Safeguards.

The specific dietary requirements of each person were assessed to ensure they were provided with sufficient food and drink. There were measures in place to reduce or eliminate the risk of malnutrition or dehydration. People were provided with a balanced diet and were able to choose what they had to eat. The way in which some staff supported people to eat their meals could be improved to make the meal time experience for the person better. Arrangements were made for people to see their GP and other healthcare professionals when they needed to.

There were good relationships between people and the staff who looked after them. Staff spoke respectfully about the people they looked after. Relatives told us the manager and the staff were kind and friendly and always made them feel welcome.

Care planning documentation was generally well written and provided an accurate account of the person’s care and support needs. Staff were provided with information about how planned care was to be provided. Care plan reviews were undertaken on a monthly basis and formal reviews with people’s family were completed at least yearly.

People were able to participate in a variety of social activities. People and their relatives were encouraged to have a say about aspects of their daily life and regular relative’s meetings were held. People living in the service their relatives or people who acted on their behalf were encouraged to express their views and opinions.

Since the last inspection there had been a change in the management and leadership of the service and this has benefitted the people who live there, their families and the staff team. Positive comments were made about the improvements by relatives and the staff team. The systems in place to monitor the quality and safety of service provision were being used effectively and had ensured that the required improvements had been made. Some minor improvements were highlighted during this inspection and have been detailed in the main body of the report. Because of the significant improvements that have been made since the last inspection, we have every confidence that these will be addressed by the provider and the manager.

The purpose of the inspection was to check what actions the registered provider and registered manager had taken in respect of enforcement notices that were issued on 29 September 2014. This inspection was carried out by one inspector. During the inspection we spoke with the registered manager and other senior managers from HC-One, one nurse and three care staff.

Whenever we undertake a full inspection of a care home we look to ensure that the service is safe, effective, caring, responsive and well-led. When we visited on 9 September 2014 we found some aspects of the service were not safe and not well-led.

Is the service safe?

The registered provider and registered manager have ensured the appropriate action had been taken when safeguarding concerns, or possible safeguarding concerns, have been raised. Robust reporting procedures have been put in place to ensure that appropriate steps are taken to safeguard people from further harm.

Is the service well-led?

Notification forms have been submitted to the Care Quality Commission in respect of previous events that had not been reported. Notifications have also been submitted regarding events that have occurred since our last visit.

There remains an outstanding compliance action in respect of people’s care records. The registered provider submitted their action plan on 28 October 2014. They told us what action they are taking to improve care documentation. We will follow up that these improvements have been made when we next inspect.

We spoke with 12 people who lived in the home and five relatives. We spoke with 11 staff members including the manager, nurses, care staff, ancillary staff and the administrator.

People had dementia and were unable to tell us about their care but they made positive comments. “Everything is good”, “I like it here and the staff all fuss over me” and “I get a bit down and confused at times but staff help me sort things out”. Relatives were complimentary about the way their loved ones were looked after.

Staff were knowledgeable about the people they looked after. They were able to relate the individual needs, choices and preferences of people.

We spent a period of time watching what was going on in Willow unit and observed how people spent their time and the staff interactions. On the whole people had positive experiences and there was good interactions between individuals and groups of people. We told the manager about areas where improvements were needed.

We looked around the whole home: it was clean tidy and well organised. The home had an ongoing programme of refurbishment and redecoration and was smarter then when we had previously visited.

People told us staff were kind and patient with them, helped them when they were anxious and were professional in their roles.

People and their families/friends, were asked for their views about their care and support and the provider took account of any comments made to improve their service.

The people that live in Pennwood Lodge have dementia and therefore not everyone we spoke with was able to tell us about their experience of life in the home. To help us to understand the experiences people had we used our SOFI (Short Observational Framework for Inspection) tool. The SOFI tool allowed us to spend time watching what was going on in the service and helped us to record how people spent their time, the type of support they got and whether they had positive experiences.

People are looked after in one of four 15 bedded units. One unit looks after people who have dementia and personal care needs only (Hawthorns) whilst the other three units looks after people with dementia and nursing care needs, (Sycamore, Willow and Laburnum). Some people using the service were able to tell us about their experiences. People in the Hawthorn unit made the following comments. “It is very comfortable here”, “I am well looked after” and “the food is very good”.

We also spoke with relatives and friends who were visiting the home. One relative told us that they had visited other dementia care units and had chosen this one because”the staff had been very welcoming and cheerful”. Another relative said “I visit every day and help my relation have their lunch. It is very important for me to still be involved in their care”.

The inspection was unannounced. When we last inspected the service in September 2014 we found there were three breaches of legal requirements. These were in respect of safeguarding adults, notifications not being sent to CQC and care records. We took enforcement action against the registered provider and registered manager in respect of two of the breaches. When we returned in October 2014 improvements had been made. We have checked during this inspection that the improvements to the other area, care records have been made.

Pennwood Lodge Nursing Home provides residential and nursing care for up to 60 people living with dementia. At the time of our inspection there were 44 people in residence. The home has four 15 bedded units, each with their own communal lounges and dining rooms and bathrooms. One unit is for people with personal care needs (residential care) and the other three units being for people with dementia and nursing care needs. All bedrooms were for single occupancy and the majority of rooms had en-suite facilities.

There was a registered manager in post at the service. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider. 

The leadership and management of the home needed to be improved. The systems in place to monitor the quality and safety of the service were inadequate. Although there was an improvement plan in place the registered manager was not steering the improvements as to their own set timescales.  Since this inspection the registered manager has resigned from post and the service is being managed by an interim manager.  This manager will be making application to the Care Quality Commission to be registered.

Although the registered manager and staff team were knowledgeable about safeguarding issues there have been a number of occasions where there has been a delay in incidents being reported to the relevant agencies. This meant that people may not have been protected from harm.

Staff did not understand the Mental Capacity Act 2005 (MCA) or the Deprivation of Liberty Safeguards (DoLS) and how to apply this to their role. Staff were unsure what actions to take if people were unlawfully deprived of their freedom to keep them safe. The MCA provides the legal framework to assess people’s capacity to make certain decisions, at a certain time. When people were assessed as not having the capacity to make a decision, a best interest decision was not being made. DoLS provide legal protection for those vulnerable people who are, or may become, deprived of their liberty. People were being deprived of their liberty however the correct processes had not been followed to ensure this was done in line with the law.

Staffing numbers on each shift have not been consistent and there have been shifts worked with reduced numbers of staff. There has been reliance upon agency staff to fill the gaps although this was reducing as new staff were recruited. Staff were provided with regular training and were supported by their colleagues to do their jobs. There were good relationships between people and the staff who looked after them. As many of the staff lived locally they had shared life experiences and were able to talk and support people’s wellbeing. Relatives told us the staff were kind and friendly and always made them welcome. People’s privacy and dignity was maintained on the whole but we told the registered manager about two examples where improvements were needed.

People received care and support that met their specific needs. Medicines were administered to people safely. Risks to people’s health and safety were assessed and appropriate management plans were in place to reduce these. People were satisfied with the food and drink they were provided with and the catering staff regularly asked people for feedback. Arrangements were made for people to see their GP and other healthcare professionals as and when they needed to do so.

For people living in the service their relatives or people who acted on their behalf were encouraged to express their views and opinions. In general, the staff listened to them and acted upon any concerns to improve the service.

We recommend that contact is made with dementia care agencies regarding the best environment to aid wellbeing.

We recommend that HC-One undertake a high level review of the management and leadership of this home.

We found a number of breaches 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.