Care and Social Services Inspectorate Wales
CareStandards Act 2000
Inspection Report
Pen Y Bryn (Pendine Park)
Pendine Park Nursing Homes
Summerhill Road
Wrexham
LL11 4YE
Type of Inspection – Focused
Date(s) of inspection – Monday, 9 February 2015
Date of publication – 27 March 2015
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Summary
About the service
Care and Social Services Inspectorate Wales (CSSIW) met with the Responsible
Individual in October 2014 where they advised us that the directors had overseen a
company restructuring during the summer which included moving Pen Y Bryn to a new
company also within the Pendine Park Care Organisation Group. As a result the provider’s
registration was no longer in place for Pen Y Bryn and effectively Pen Y Bryn was being
carried on by a provider that was not registered to do so.
CSSIW accepted that this was an unintended consequence of the company restructuring.
CSSIW were satisfied that there were no adverse outcomes or increased risks for people
living at Pen Y Bryn and as a result therefore agreed that Pen Y Bryn should continue to
operate while a registration application was submitted. An application to register the new
provider has been submitted and the assessment of this is almost complete. There are no
contraindications to approval at this stage.
What type of inspection was carried out?
We (CSSIW) undertook a planned focussed inspection on 9 February 2015 between the
hours of13:00 and 18:00.
Three adult protection referrals to the local safeguarding authority had been made in the
past twelve months in relation to poor care, non accidental injury, and safety issues. Two
referrals were made by the Manager of the service. One was upheld, the other was
inconclusive. One referral alleging poor care of a person admitted to hospital from the
service was not proven.
As part of the inspection process we sent out questionnaire’s to people living at the
service, relatives and staff. We also spoke with people living here, staff, the manager and
responsible individual.
We reviewed the following information:
Four random care plans
DoLS (Deprivation of Liberty Safeguards) applications
Regulation 38 Notifications
What does the service do well?
The service identifies and manages situations were potential safeguarding situations have
or could occur. These situations are supported by good record keeping and supporting
documentation. There have been examples of poor practice that we have reviewed via a
Regulation 38 notification sent to us by the manager (which the service is required to send
to CSSIW if any event which affects the wellbeing of an individual) when the service or
support to an individual that should have been provided by the local hospital was
considered to be poor. The manager has no hesitation in raising such issues, therefore
protecting people’s rights and acting on behalf of people that are unable to voice their own
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concerns.
What has improved since the last inspection?
The manager told us that a re arrangement of the floors has taken place, so that people
assessed with high nursing needs are accommodated on the ground floor, and people
considered suitable for re enablement are accommodated on the first floor.
There is an enrichment programme in place at the service. In response to this two staff are
able to use the mini bus so that people can access places of interest, away from the
service.
The manager attends the Motor Neurone Development meetings at the local hospital, so
as to ensure current practices and developments are available for the staff team at the
service.
New flooring has been laid and it is anticipated that the downstairs lounge will be
refurbished.
What needs to be done to improve the service?
In accordance with National Minimum Standards for Care Home for Younger Adults
we identified the following area for improvement.
National Minimum Standard, 26 with regard to training and development. The manager
has identified a specific need to provide staff with training for younger adults with acquired
brain injury. The statutory services for this training have ceased to operate and therefore
the training in this area of expertise can be limited.
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Quality Of Life
Overall the quality of life for people living here is good. People have a variety of needs
which require a skilled, versatile and dedicated approach from the staff team. The
manager is experienced and is supported by an experienced team of nursing and care
staff who promote the welfare of people living at the service through encouragement and
a willingness to ensure people experience a good quality of life within the limitations of
their complex needs.
People living within the service can expect they will be motivated by the staff team to
move on to a more independent living situation with some support if their medical
prognosis is good. This is because people’s individual needs and abilities are recognised
and supported by the staff that believe in the rehabilitation of individuals if it is at all
possible. We spoke with people living at the service that are challenged on a daily basis
by their specific conditions. It was clear to us that people living here have the greatest
respect for the determination held by the manager and staff group that support them, for
them to succeed and achieve as much as they can within the limitations of their disability.
We reviewed the twelve returned questionnaires from people living at the service, staff
and relatives. Eleven of the comments were positive each indicating the service provided
is good and the support to people and staff is also good. Comments such as “the home is
clean, with well presented staff who always listen to your views,”good staff and good
manager”. “ I like the freedom to visit at any time”. One comment made that should be
reviewed by the manager is that more staff are needed because on occasions the
service is short staffed. We had spoken with the manager during the inspection regarding
staffing levels and there had been occasions when staff did not arrive for work due to a
variety of reasons, this we know happens in services on occasions. We were advised
that vacant shifts are covered wherever possible and there is bank staff available to fill
the gaps created by unforeseen circumstances. Normally staffing levels are maintained.
People are well cared for and their individual personalities and tastes are respected by
the staff. This is because we observed staff offering various clothing choices to people
that were going out, and we visited a person in their room where their personal items
were displayed. We observed the interaction between staff and people at the service. We
noticed that people with limited communication skills were able to indicate their joy and
happiness through their facial expressions when they identified members of staff that
they clearly were fond of. We spoke with staff regarding their support of people with
communication needs and were impressed by their knowledge and ability in identifying
the smallest detail of people’s facial expression, body language and moods. People told
us staff were supportive to them and could take a firm approach, however this was
identified by them as being for their “own good”, and that they often needed this
approach to assist them towards maintaining their independence.
People living here can expect to have a care plan in place which identifies the degree of
support they require. Care plans are in place and have been improved to include one
page profiles. These profiles give immediate information about the individual which forms
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the basis of communication when people first meet. All the care plans have been
reviewed and a separation between people that require technical nursing and those
people whose support does not require intensive nursing has been made. This means
the service has two types of care plans in place. We looked at four individual care plans.
Two people that required nursing and two people that did not have any nursing needs.
Included in the care plans was information concerning applications to the local authority
to request a DolS (Depravation of Liberty Safeguards).These requests are made to the
local authority when the service identifies situations where people could be at risk if a
situation occurs in which they could come to harm. We were aware of these applications
as the service is required to notify CSSIW when an application is made. From the care
plans we could seethe reasons for the applications being made. The care plans were
well written with evidence of regular reviews of peoples needs taking place.
People can be assured that there is an arrangement in place to support them to maintain
their hobbies and interests. The service employs a dedicated activities person. People
can also be confident that the service will provide opportunities for people to experience
“going away on holiday”. We discussed with the manager and a member of staff the
arrangements in place for three people to experience a holiday by the sea. This has
taken meticulous planning and communication with other agencies, and we spoke with
the staff member who will have responsibility for one of the people going, and they have
been involved with the person’s preparation for the holiday. We also met the person who
by their responses to us is clearly looking forward to the experience. We recognise that
some people living at the service with significant health conditions often prevent activities
taking place because their health needs take priority.
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Quality Of Staffing
The inspection focussed on the theme quality of life CSSIW did not consider it necessary
to look at the quality of staffing on this occasion. However this theme will be considered
at future inspections.
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Quality Of Leadership and Management
The inspection focussed on the theme quality of life. CSSIW did not consider it
necessary to look at the quality of leadership and management on this occasion.
However this theme will be considered at future inspections.
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Quality Of The Environment
The inspection focussed on the theme quality of life. CSSIW did not consider it
necessary to look at the quality of the environment on this occasion. However this theme
will be considered at future inspections.
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How we inspect and report on services
We conduct two types of inspection; baseline and focussed. Both consider the experience
of people using services.
Baseline inspectionsassess whether the registration of a service is justified and
whether the conditions of registration are appropriate. For most services, we carry out
these inspections every three years. Exceptions are registered child minders, out of
school care, sessional care, crèches and open access provision, which are every four
years.
At these inspections we check whether the service has a clear, effective Statement of
Purpose and whether the service delivers on the commitments set out in its Statement
of Purpose. In assessing whether registration is justified inspectors check that the
service can demonstrate a history of compliance with regulations.
Focused inspections consider the experience of people using services and we will
look at compliance with regulations when poor outcomes for people using services are
identified. We carry out these inspections in between baseline inspections. Focussed
inspections will always consider the quality of life of people using services and may look
at other areas.
Baseline and focused inspections may be scheduled or carried out in response to concerns.
Inspectors use a variety of methods to gather information during inspections. These may
include;
Talking with people who use services and their representatives
Talking to staff and the manager
Looking at documentation
Observation of staff interactions with people and of the environment
Comments made within questionnaires returned from people who use services, staff
and health and social care professionals
We inspect and report our findings under ‘Quality Themes’. Those relevant to each type of
service are referred to within our inspection reports.
Further information about what we do can be found in our leaflet ‘Improving Care and
Social Services in Wales’. You can download this from our website, Improving Care and
Social Services in Wales or ask us to send you a copy by telephoning your local CSSIW
regional office.
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