Pentland Close

We identified two breaches of the legal regulations in relation to safe care and treatment and staffing. The person was not always safe and did not always have safe care and treatment. Risk assessments were not robustly reviewed in relation to higher risks. Support plans required further detail to effectively guide staff in supporting the person and to mitigate any risks. Therefore, the care and treatment of the person was not planned to ensure the person’s needs were met. The provider had not ensured thorough and effective systems were in place for monitoring accidents and incidents. Processes were ineffective in ensuring the relevant action was taken and lessons shared with staff to ensure the most effective support was provided to the person. However, the provider had implemented processes to monitor accidents and incidents which will need to be embedded and sustained.

Staff had not consistently received supervisions and their training had not always been assessed to ensure they had the skills for their role and duties they were employed to perform. The staff’s competencies had not been reviewed to support safe care and treatment. However, the provider was implementing systems to rectify this.

Feedback received from partners identified concerns whereby the person’s dignity was not always upheld. We identified areas of the service where the principles of RS,RC,RC for people with learning disabilities and autism were not being met.

We identified one breach of the legal regulations in relation to person centred care. The person’s needs were not always supported and therefore this does not support person-centred and individualised care. Leaders and staff were unable to describe how the person’s needs were continually assessed and goals set to support the best possible outcomes. Therefore, the care and treatment was not planned to support meeting the person’s individual and person-centred needs. Care records were not always person centred and lacked detail which meant decisions could not be made to support the high standards of delivery of person-centred care. There were gaps in the recording of the overall health records of the person’s needs. Therefore, this impacts on the lack of person-centred care. There were no records of the goals the person wished to achieve which contributed towards to lack of person-centred care and care planning. The person did not always have comprehensive care plans to guide safe practice. Person-centred care could not always be delivered as we identified there was no health action plan in place to ensure the needs of the person were met. This meant person-centred care could not always be delivered as there were shortfalls in the overall records of the care needs of the person. Person-centred care could not always be delivered as the records of the person lacked detail on identified health needs and how and where staff should use communication aids. Person-centred care could not be effectively delivered as updates had not been recorded on changes to the way the person was now eating meals. The system for recording health information was not robust. This required staff to go back to review records to find the reason and outcome for appointments. This impacted on person centred care as ineffective recording meant the staff could not implement high standards of person-centred care.

The person was observed to be happy with the support provided by staff. The person was treated with kindness and the person’s privacy was respected. The staff engaged in conversations with the person and understood when a change of what they were doing was needed. Staff understood how the person was treated, mattered. The person met their loved ones and led an active lifestyle engaging in activities to support their health and well-being.

The person was supported by staff that knew them well. Staff supported the person to access education and health and were actively involved in working with professionals.

We identified one breach of the legal regulations in relation to good governance. There had been a lack of provider oversight of the service. The provider failed to ensure clear and effective governance systems were in place to assess, monitor and reduce the risks to the person and the service. Therefore, improvements could not be identified to improve on care and service delivery. Audits had not been regularly completed and where they had been, action plans had not been implemented. Therefore, the service did not have accountability for risks identified and improvements to be made. Care records were not always written in a person-centred way to improve care and support efficient recording. Leaders acknowledged systems were not robust and have implemented new audits and monitoring systems. However, this will take time to embed, review and monitor to support their governance and auditing practice. The leaders were not fully aware of their responsibilities under the Mental Capacity Act 2005 (MCA). The Mental Capacity Act 2005 (MCA) policy was out of date and had not been reviewed. The leaders had not ensured the person’s relatives had the authority to consent on the person’s behalf. Senior leaders had not ensured staff were supported by a capable and compassionate management team. There had been a lack of support and supervisions for staff which meant a positive culture of learning and improvement could not be embedded. This also meant leaders were not alert to any examples of poor culture that may have had a negative impact on staff. The leaders recognised they needed to give their staff support and enable an open and transparent culture for staff to be able to approach the leaders.