Pentland Close

Not everyone who used the service received personal care. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do we also consider any wider social care provided.

People’s experience of using this service and what we found

The provider did not operate effective quality assurance systems to oversee the service. These systems did not ensure compliance with the fundamental standards and identifying when the fundamental standards were not met.

The provider did not ensure consistent actions were taken to reduce the risks where possible and meaningful plans were not in place to minimise those risks. Effective recruitment processes were not in place to ensure that people were protected from staff being employed who were not suitable. The management of medicines was not always safe. Staff were not up to date with, or had not received, their competency checks and mandatory training. When incidents or accidents happened, it was not recorded clearly and consistently that it was fully investigated, and if lessons were learnt. The provider did not ensure that clear and consistent records were kept for people who use the service and the service management. People, their families and other people that mattered were involved in the planning of their care. However, the support plans did not contain all information specific to people’s needs and how to manage any conditions they had. Staff did not have all detailed guidance for them to follow when supporting people with complex needs.

We have made a recommendation about seeking guidance from a reputable source to ensure the Mental Capacity Act legal framework and the provider’s responsibility to record people’s and children’s decisions was followed accordingly. We have made a recommendation about seeking guidance from a reputable source to ensure the principles of the Accessible Information Standard were met. We have made a recommendation about gathering and acting on people’s, children’s, relatives, and staff’s feedback.

We judged people were supported to have maximum choice and control of their lives and staff did support them in the least restrictive way possible and in their best interests. However, the policies and systems in the service had to be improved to continue supporting this practice.

The elative said they felt their family member was safe with the staff providing their support and care. Staff understood their responsibilities to raise concerns and report incidents or allegations of abuse. The staff team followed procedures and practices to control the spread of infection using personal protective equipment. The relative said staff were caring and kind and we observed this. Staff understood how to treat people and children with care, respect, and kindness. Staff upheld people's privacy and responded in a way that maintained their dignity. The relative said staff were consistent and effective in the support they provided. Staff said the staffing levels were sufficient to do their job safely and effectively.

The management team appreciated staff contributions and efforts to ensure people received the care and support they needed. Staff said they communicated regularly with each other and worked well together. They felt they could approach the management team at any time. Staff had support via supervision and appraisals sessions. The management team was working with the local authority and different professionals to investigate safeguarding cases and other matters relating to people’s health and wellbeing. The professionals were mostly positive about the service and noted where the service and management has improved.

There was an emergency plan in place to respond to unexpected events. There was a process to manage complaints effectively and according to the provider's policy. The provider informed us about notifiable incidents in a timely manner. Staff deployment and management of shifts ensured people received their care as planned.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people. We considered this guidance as there were people using the service who have a learning disability and or who are autistic.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

This service was registered with us on 16 October 2020 and this is the first inspection.

Why we inspected

This inspection was supported by a review of all the information we held about this service. The service has not been inspected since their registration.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to quality assurance, risk management, notification of changes to statement of purpose, record keeping, management of medicine, staff training and competence and recruitment. We have made a recommendation about meeting the Accessible Information Standard and Mental Capacity Act legal framework. We have made a recommendation about seeking and using feedback from people, staff and others to improve the service.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.