Pentland Close

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

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.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The person experienced staff working together to support them. A relative told us they felt their loved one’s needs were comprehensively assessed before they started using the service and regular reviews were held to monitor progress. They told us the service contributed well in multi-agency reviews.

Leaders and staff were unable to describe how the person’s needs and aspirations were continually assessed, how goals were set and achievements celebrated. Senior managers told us they felt the person received personalised support although acknowledged the support plans needed to be updated. Therefore, this contributed to the lack of person-centred care. Our assessment also identified care records were not always person centred and lacked important detail which meant decisions could not be made to support the delivery of high standards of person-centred care.

Partners feedback received identified concerns with regards to the person’s independence, socialising, access to peers and activities. We were informed, “[Person] enjoys the company of others.” However, the person may not have the opportunity to socialise with peers as we were told, “there is no chance to socialise with peers [person] own age as [Person] spends all time with [person] carers.” With regards to socialising with peers, partner feedback confirmed they were informed on a day out, the person went with carers. With regards to independence skills, we were told, “we are not sure this is as actively encouraged at Pentland Close.” Feedback from partners confirmed, “[Person] always speaks highly of the staff at Pentland Close and is excited to see them.”

Systems were not in place to ensure care records and assessments were up to date and they lacked details to support the delivery of person-centred care to meet the person’s needs. The person’s goals and aspirations were not recorded. Where the person had health conditions, comprehensive records were not in place nor health action plans on what support the person needed to maintain their health. This meant and we also identified there were shortfalls in the overall recording of the person’s health needs. We identified healthcare professionals had written to the service outlining the support they would provide to the person but the leaders were unaware of this letter. However, we identified the leaders had a meeting with the healthcare professionals in the diary. The communication plans did not have guidance and examples on how the resources needed to be used by staff. The communication care plan did not give examples of where and how staff should use the resources. In addition to this changes to the way the person was now eating their meals had not been updated. The lack of detailed and comprehensive assessments and care records meant there was a risk to the person, the delivery of individualised person-centred care and the person’s needs may not be holistically met. The service had a consistent staff team to identify changes in behaviour of the person and understand if the person was in pain. The lack of accurate records and care planning meant the service could not maximise the effectiveness of the person’s care and treatment by holistically assessing their health, care, well-being and communication needs with them. Therefore, the lack of recording of accurate care records impacted on the delivery of high standards of person-centred care.

We did not look at Delivering evidence-based care and treatment during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at How staff, teams and services work together during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at Monitoring and improving outcomes during this assessment. The score for this quality statement is based on the previous rating for Effective.

The person benefitted from competent staff working together and with them. A relative told us staff were skilled at supporting their loved ones in making decisions. They told us, “They are always talking to [person]. If [person] didn’t want to do something [person] just wouldn’t do it so [person] tells them and they all work it out.”

Feedback from senior managers demonstrated they did not have an understanding of the principles of the Mental Capacity Act 2005 (MCA). They were not aware of their responsibilities in completing decision specific capacity assessments and where applicable, best interest decisions. However, staff were able to describe how they supported the person to gain their consent. One staff member told us, “The MCA is about someone’s ability to process things and decisions. [Person] likes to think slowly. You have to keep repeating it and give lots of time. Then you will get a response.”

A review of the processes identified the principles of the Mental Capacity Act 2005 (MCA) were not always followed to protect the person’s rights. Mental capacity assessments and best interest decisions were not actioned for all of the restrictions in place. We requested these were completed for all restrictions in place and forwarded to us for review. We noted there was no capacity assessment of one to one or two to one support. Dates for review were not noted. We also identified that one of the best interest decisions had the name of another person noted and for another need. Whilst the correct processes to ensure any restrictions that were in the person’s best interest were not followed, we found the service had considered the least restrictive options and had taken steps to reduce restrictions which gave the person great freedom and autonomy.