Pennine Care Centre

On this page

• 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

Our rating for this key question has changed to requires improvement. We found 1 breach of the legal requirements. The provider was working towards improvements however, these had not yet been fully embedded, and improvements had not yet been sustained. Not all staff felt involved in the changes or felt the leadership team were approachable; as such, not all staff felt confident speaking up if things were not right. Improvements were required to leaders’ oversight of the service to ensure improvements could be identified and embedded. Systems to provide oversight and ensure compliance were not always effective, for example, notifications were not always submitted to CQC when required and records were not always accurate. Steps to help people make links to their local community were in place and people had access to health care services as needed.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Leaders provided details of staff meetings and other actions they had taken, showing they were working with staff to involve them in the developments and planned improvement at the service. However, feedback from staff was mixed as to whether they felt involved in the shared direction and culture at the home. Whilst some staff felt the home had improved there were other staff who told us they felt unsupported by leaders to make the improvements needed. Whilst staff felt able to raise concerns anonymously to organisations outside of the home, we were concerned this was due staff feeling not heard by their leaders or due to the culture within the home.

Processes were in place to help develop a shared direction and culture. Team meetings were held and they kept staff informed about relevant information. Initiatives to help value and appreciate staff had been introduced, for example, ‘employee of the month.’ Whilst processes were in place to help develop a shared direction and culture these were not effective as they could be as not all staff were confident in speaking up.

Leaders told us they felt they were approachable, fair and transparent. They provided evidence of how they had supported staff including, flexible work, career progression, emotional and practical support and had openly discussed with some staff business operations. However, not all staff felt the leadership team were approachable, fair or transparent.

Leaders told us they felt they had processes in place that demonstrated they were compassionate and inclusive. However, as not all staff felt confident in approaching leaders or confident that their actions would be fair or transparent we were not assured these processes were fully effective. Roles to help develop good practice in areas such as dementia, mental health, dignity, communication and support for new staff were in development. Leaders told us a dignity champion had been appointed earlier this year. Leaders signposted staff to a support organisation who could help staff settle in the UK. Complaints were managed in a way that helped to promote people’s rights.

Leaders told us they felt they acted on any issues staff made them aware of. However, staff views on whether they felt it was safe to speak up about any concerns was mixed. Some staff felt leaders would listen and be supportive while other staff felt leaders had made staff anxious in the way they had dealt with previous issues.

Although a whistle-blowing policy was in place at the service we were not assured it was effective as staff did not always feel listened to and did not always raise concerns. Whistle-blowing is a law that protects staff from being treated unfairly by their employer if they have raised genuine concerns about a person’s care.

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.

Leaders told us they used a range of audits to check on the quality and safety of services. Responsibility for which staff were responsible for completing each audit was clearly identified. However, the audits had not always identified actions that needed to be taken in order to improve people's experience or safety of their care.

Leaders had an action plan in place designed to improve the service. At the time of our assessment improvements had not yet been sustained and were still being embedded. The action plan contained actions identified by Leaders themselves as well as actions in response to external agencies finding risk issues and concerns within the home. We were not assured that the services own governance structures were robust or effective enough to identity these issues without support from external agencies. Whilst a range of audits helped to identify shortfalls and improve quality, these were not always effective. For example, we found shortfalls in cleanliness and infection prevention and control standards. Improvements were needed in leaders ‘oversight and governance of safeguarding incidents. For example, the provider’s safeguarding log did not contain all incidents raised with the local authority and did not contain sufficient detail to allow any analysis of themes that could help to inform improvements and lessons learnt. The registered provider and manager are required to notify the Care Quality Commission of certain events and incidents. The provider had submitted some but others had not been reported to the Care Quality Commission as required. The provider’s processes for effectively identifying and notifying the Care Quality Commission as required were not always effective. Records were not always complete or accurate. Food charts for one person contained another person’s records and did not fully describe what food people had eaten. Care plans were inconsistent over equipment needed to transfer and personal care preferences. Leaders said they would update their records and work on improvements with staff. Whilst the provider was aware their record keeping was not always accurate or complete, the actions they had taken to improve this had not yet been fully embedded and improvements had not yet been sustained.

People told us they were happy living at Pennine Care Centre. People felt if they had given feedback or made a complaint, this had been listened to and resolved for them and people were of the general opinion that the home was well-managed.

Leaders worked with a range of external community health and social care services to help ensure people received the care they needed.

Some partners had significant concerns that the management and governance systems at the service were not effective at sustaining improvements and identifying shortfalls to the quality and safety of people’s care. Not all partners felt assured that the recommendations and guidance they provided to help ensure people’s safe care and the delivery of safe care from staff had been consistently followed. They therefore felt improvements in people’s care were not always sustained. Other partners told us the new registered manager had implemented new systems that from their perspective, had improved effective information sharing and responsiveness to people’s health needs.

Staff had guidance to follow to ensure they could contact relevant external health and social care agencies. However, the provider could not assure us this had always been followed as we found not all incidents had been reported to the local authority and the Care Quality Commission as required. Leaders supported people’s involvement in the local community by arranging regular inter-generational events and visits from religious leaders to help meet people’s faith needs. A range of entertainment and activities was arranged for people to participate from if they wanted to.

Leaders told us about the actions they had taken themselves to try and improve the service. An action plan was in place and contained actions taken in response to other visiting professionals when they had identified improvements as well as actions identified by Leaders themselves. Leaders had not yet fully embedded their own effective checks to ensure they identified all improvements needed without the input of other external professionals.

A quality assurance policy was in place with details of how the service would assess and monitor the quality of the service. However, we were not assured this was effective. Whilst leaders were identifying some issues for improvement themselves, feedback from external agencies was also being used to help improve the service as leaders were not always identifying all issues themselves.