Pentland Close

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

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 The Mental Capacity Act 2005 (MCA) policy was out of date and had not been reviewed.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.

This service scored 46 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Senior managers acknowledged that management systems had not always been robust which had led to some staff not feeling valued in their roles. They told us of the steps they had taken to rectify this and enhance the support to staff. They told us, “It’s a big lesson for us. We need to give staff the support and be at the services far more. We want an open and transparent culture and for staff to feel they can come to any of us.” Staff told us they now felt supported in their roles. Staff told us, “I think I am listened to. The staff morale here is particularly good now. We are a team who help each other out. The change to having a core team here has been good for the service users we are supporting. They get to know us and see our faces day to day. They learn our skills as well and respond to that.”

Processes identified the service was not always managed well. Senior leaders had not ensured staff were supported by a capable and compassionate management team. There had been a lack of support for staff with a lack of supervisions to provide the opportunity for them to discuss their performance and any concerns. Staff meeting minutes showed an authoritarian approach with staff being given instruction rather than being supported to share their views. Audits and action plans had not been effective in ensuring the service was well managed. Once concerns regarding the management of the service were highlighted, the senior leadership team had taken action to ensure skills gaps were filled. This had led to systems being implemented to encourage staff to raise any concerns and to monitor the performance both of individuals and the service. A period of time is required to ensure these systems are sustained and embedded into practice.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The senior managers acknowledged systems had not been robust enough to identify and address areas of concern. They had implemented new audits and monitoring systems although these had not yet been embedded into practice. They told us, “We know we are not where we need to be yet, we’re a work in progress. We have the support from the consultant and the manager and are improving all the time.” In addition, the senior managers told us, “With what we are putting in place now, I don’t think there will be any excuse for us being able to say it’s not been done going forward because it will be picked up in audits. We know the expectations now and all the documents are live documents so we can continually check what has been done.”

There had been a lack of provider oversight of the service. Audits had not been completed regularly and there was not a system in place for regular monitoring of managerial tasks being completed or the quality of work. Where audits had taken place, these had not resulted in action plans being implemented and monitored. The policies and guidance were not all up to date nor consistently followed. The Mental Capacity Act (MCA) 2005 policy was out of date. The leaders had not ensured the person’s relatives had the authority to consent on the person’s behalf. The care records were not always written in a person-centred way to improve care, support efficient recording and to have oversight of the person’s care and any risks. We identified health records of the person were not accurately recorded to provide a comprehensive overview of the appointments. 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. The service was open and transparent regarding their learning and actions following concerns being raised and had implemented a number of initiatives and skills training. These included investing in support from a consultant and a manager with a positive track record, moving to a core staff team for people and additional training. However, any systems implemented will need a period of time to fully embed and effective monitoring will be required.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.