The Care Quality Commission (CQC) has rated Penley Grange in Stokenchurch, inadequate overall, following inspections in April and May.
Penley Grange is a residential care home providing personal care for up to six people with a learning disability or autistic people. The service is run by Centurion Health Care Limited.
CQC carried out an unannounced inspection partly due to concerns about poor management oversight following concerns raised about the quality and safety of people's care at the adjoining care home, Penley View. Inspectors had also received concerns about the quality of people's care, staff culture and management of risks.
Following the inspection, the overall rating for the service dropped from good to inadequate. The ratings for safe, effective, responsive and well-led also dropped from good to inadequate. Caring dropped from good to requires improvement.
The service is now in special measures which means it will be kept under review and re-inspected to check that improvements have been made. If significant improvements have not been made, CQC will take further enforcement action.
Deborah Ivanova, CQCs director for people with learning disability and autistic people, said:
“When we inspected Penley Grange, we found a service where there was previously a lack of managerial oversight.
“What was most concerning is the way people were made to feel, in a place that was supposed to be their home. There were instances where people living there showed signs of being distressed and the response from staff did not consistently respect people or afford them the dignity each person is entitled to. People were relying on staff to act as their advocates to keep them safe and listen and act on their concerns and it’s unacceptable that those they relied on were treating them this way.
“People were not being supported to lead meaningful and empowered lives. The provider didn’t focus on people's quality of life, and care delivery wasn’t person centred. Staff didn’t recognise how to promote people's rights, choice or independence.
“Two safeguarding incidents on 23 and 24 April 2022 were not reported to the local authority until 11 May 2022. This meant there was no assurance the service was identifying or reporting safeguarding concerns in a timely manner.
“The building itself was in need of urgent maintenance work to address health and safety risks. The poor maintenance to the home’s environment did not help meet people’s needs. For example, one person’s curtain rail had broken and wasn’t fixed until after the inspection ended. This meant the person’s bedroom window, which overlooked the carpark, had no curtain across half the window throughout the inspection. The person was already known to experience poor sleep and we were concerned the service had not taken timely action to protect the person’s privacy.
“We have told the provider to make urgent improvements to ensure that people and staff are safe, and we will monitor the service closely to ensure these are made and fully embedded. We have taken enforcement action and once we have completed our legal processes we will discuss at a later date.
“A care consultancy commenced work on-site shortly prior to our inspection and are supporting a new home manager to make sure the improvements we want see are in place and fully embedded.”
Inspectors found the following during this inspection:
- People's relatives said 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
- 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 did not capture people's preferences and aspirations
- 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
- Risks to people were not were not always appropriately assessed or measures taken to enable people to live safely in their home. This included risks associated with caring for people with epilepsy
- There were not sufficiently trained or supervised staff to safely meet the needs of people. There were people at the service who had needs relating to autism, learning disabilities, epilepsy but some agency staff had not had enough training in these areas. They also had not received training in positive behaviour support
- Medicines were not always managed safely. Some medicine, which was needed for a person in the event of an epileptic seizure, was not available in the building. Some people were prescribed 'as and when' medicine but there was not always enough information for staff to safely and consistently administer certain types of medicines
- Staff did not always communicate with people in ways they understood
- Behaviours and incidents were not always recorded and analysed to look for trends. This meant there was little opportunity for lessons to be learned when things went wrong.