20 July 2022
During an inspection looking at part of the service
We undertook an inspection of Turning Point – Pendlebury House as part of a random selection of services rated good and outstanding to test the reliability of our new monitoring approach. We only looked at two of our key questions; how safe and how well-led is the service?
Following this inspection our rating of safe, well-led and the overall rating of this location went down. We rated it as requires improvement because:
- Areas of the environment were dated and in need of refurbishment. These areas included the rehabilitation kitchen, communal bathroom and the ensuite patient bathrooms. The fire doors had also been identified by the service for replacement, but this had not yet been completed. The service did not have a specific maintenance or refurbishment plan, although managers had identified areas of the hospital that they felt needed refurbishment. The service also had maintenance jobs that were pending and had not yet been completed.
- The service’s processes for reviewing and monitoring the environment and maintenance were not always completed in line with the provider’s expectations. There were gaps in some of the weekly environmental checks for the service. It was also not clear that these processes identified every issue or how issues identified in these audits were monitored to ensure they were addressed in a timely manner. The processes did not ensure that managers had appropriate oversight of all the identified issues and how they were being monitored and addressed.
- The hospital’s governance processes and checks had not ensured that all issues in the service were identified and addressed. There were out of date items in one of the first aid kits. One of four risk assessments checked had not been reviewed in line with the provider’s expectations. Two of the five prescription cards checked had missed signatures for medication. The service had written a recent police incident notification form but had not submitted it to CQC. All staff were not aware of the location of the ligature cutters in the hospital. The service had some low compliance rates for mandatory training courses.
However:
- The service provided safe care. Staff generally assessed and managed risk well. They minimised the use of restrictive practices and followed good practice with respect to safeguarding.
- Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. Patients gave positive feedback about the service, staff and management.
- Despite recent challenges in respect of staffing and vacancies in the service, staff and managers were passionate about their jobs and attempted to limit the impact on the care and treatment of patients.