Pentland Close

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We identified two breaches of the legal regulations in relation to safe care and treatment and staffing. The person was not always safe and did not always have safe care and treatment. 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. Therefore, the care and treatment of the person was not planned to ensure the person’s needs were met. The provider had not ensured thorough and effective systems were in place for monitoring accidents and incidents. Processes were ineffective in ensuring the relevant action was taken and lessons shared with staff to ensure the most effective support was provided to the person. However, the provider had implemented processes to monitor accidents and incidents which will need to be embedded and sustained. Staff had not consistently received supervisions and their training had not always been assessed to ensure they had the skills for their role and duties they were employed to perform. The staff’s competencies had not been reviewed to support safe care and treatment. However, the provider was implementing systems to rectify this. Feedback received from partners identified concerns whereby the person’s dignity was not always upheld. We identified areas of the service where the principles of RS,RC,RC for people with learning disabilities and autism were not being met.

This service scored 62 (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 benefitted from support from the staff. The persons relative told us they felt staff had done a good job in supporting their loved one through a difficult period. They felt staff had communicated well with other professionals to achieve the best outcomes for the person.

The management team acknowledged that systems for monitoring accidents and incidents had not always been robust. They told us, “Until this year there wasn’t a thorough analysis of concerns. We were not doing the follow-up action and lessons learnt robustly.” Staff were aware of how to report accident and incidents and felt the managers responded to these concerns. Comments included, “Once there’s an incident staff then complete and send to the senior or the Nominated Individual. That is looked into for further investigations and outcomes. If it’s an emergency, we call them [managers] for their advice. When [person] was agitated [person] support plan was changed and we sought medical advice.” Our assessment identified effective systems and processes were not in place to address issues and identify learning opportunities.

Partners feedback received identified concerns whereby the person’s dignity was not always upheld. We were told of soiled clothes left in the person’s bag and lack of communication with regards to which staff were supporting the person that day. We were told, "This can be unsettling." However, partners feedback received confirmed the service, “respond quickly and issues have been resolved straight away” and “[person] is living in a well-supported and safe environment.”

The processes implemented had not consistently ensured accidents and incidents were tracked, reviewed and monitored. Therefore, processes were not always effective in ensuring the relevant action was taken, the most effective support provided to people and learning shared. Regular audits had not been actioned and where they had been completed and concerns identified, these were not addressed through effective monitoring. Our review of the processes identified accidents, incidents and learning from them had not been shared to improve on staff practice and embed high quality care. The leaders had not established effective processes to support people to meet their needs.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

The person experienced being supported by staff to feel safe. The relative spoken with told us, “I think [person’s] totally safe. If [they] didn’t feel safe it would be written all over [their] face and it would show in [their] behaviour.”

Staff were aware of their responsibilities in safeguarding people from abuse. They were able to identify the different types of potential abuse, the signs of concern to look for and reporting procedures. Staff comments included, “If we have concerns of abuse first we will contact the managers and let them know. We work hand in hand with the family so we would also contact them and the social worker. Managers would report to safeguarding but if they don’t do that we can go to safeguarding.”

We observed the person appeared comfortable in the presence of staff and the senior management team. They moved freely around their home, chatted openly with staff and shared jokes. Information regarding how to share and report safeguarding concerns was accessible to the person and the staff team.

Staff were aware of their responsibilities and following processes in safeguarding people from potential abuse and how to report any concerns. Staff had completed safeguarding training and the service had a safeguarding policy. Leaders worked with professionals with any safeguarding concerns.

The person experienced the support of staff that knew the person well and supported them to manage risks in a positive manner. The person benefitted from the staff that demonstrated a calm and gentle approach. Despite this, there was a continued risk staff would not support the person effectively due to the gaps in guidance provided to them. The care plans and risk assessments required more detail and guidance especially in relation to higher risks. The guidance lacked detail with how the person was to be supported with community access and in relation to identified health needs.

Staff knew the person well and demonstrated a good understanding of how to support the person to them keep safe. Staff were aware of the risks to the person’s safety and how to respond when they became anxious. Staff felt supported by the senior management team. We identified risk assessments in relation to higher risks had not been robustly reviewed to guide staff in supporting the person.

Observations identified staff knew the person well and supported them to manage risks in a positive manner. Staff demonstrated a calm and gentle approach. However, there was a continued risk staff would not support the person effectively due to the gaps in guidance provided to them and the care plans lacking detail. Gaps were identified in the recording of the overall health records of the person’s needs. The guidance lacked detail on how the person was to be supported with community access including what details staff needed with them if the person decided to leave the staff, when out. There was no guidance on what staff should do when the person left the service without staff support nor was the relevant documentation completed.

Processes were not always in place to manage risks. The risk assessments had not been effectively reviewed in relation to higher risks. The positive behaviour support plans and risk assessments required further details, clarification and guidance to support staff in managing risks and potential triggers. The potential triggers that were recorded were not sufficiently descriptive and staff had previously struggled to support the person. The care records lacked detail which meant safe care could not always be delivered. The positive behaviour support plan noted an activity should be offered if the person was highly distressed but there was no guidance on what would be a safe thing to do at this point. There were gaps in the recording of the overall health records of the person’s needs and therefore risks could not be efficiently assessed. The guidance provided to staff in relation to community access was not comprehensive. There was no reference to the use of public transport, at what point staff should consider suggesting returning home, where staff should sit in the car, what details staff should have with them should the person decide to leave them when out.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

The person experienced support from staff who knew them well. The person’s relative told us they felt staff were skilled in their approach. They told us, “We couldn’t deal with things in the way they can. I’d say they were very skilled.” They told us they felt there were always sufficient staff available to support their loved one and give them the opportunity to go out.

Staff told us they felt the training they received was relevant to their role and they felt supported by managers. One staff member told us, “The Induction covered everything I needed to know and I shadowed staff initially. The training is good we do on-line and in groups. I did the Care Certificate training on-line and was also assigned other courses and questions to answer for competence. I have done this in previous jobs too.” Staff had not consistently received supervision and their training had not always been assessed to ensure they had the skills required for their role. Although the provider assured us systems to address these concerns were in the process of being implemented, this needed time to be embedded into practice and sustained. They told us, “We thought supervisions were happening before, but they weren’t being done regularly. We have a matrix on our new system which can be accessed by all managers at anytime so we can audit.” One staff member told us, “We have supervisions. They are becoming more regular.” Staff told us they felt there were sufficient staff to support people’s needs. Staff said, “We are a team here now. There are enough of us, and it works well.”

We observed the person received prompt support from staff. They appeared happy in the company of staff and there was a positive atmosphere between the staff, leaders and the person..

A review of the processes identified staff supporting the person had completed the on-line element of the Care Certificate, but their competencies had not been reviewed. The service had requested this was completed by the consultant supporting them and dates were in the diary for this. This concern was also highlighted during our last inspection. Staff had not received regular supervisions. More regular plans had been implemented since January 2024 although prior to this there were few records of supervisions taking place. This demonstrated a lack of monitoring by the registered manager and provider and meant staff did not have the opportunity to raise concerns, monitor their progress or discuss what support they required. Improvements had been made in the way staff were recruited with relevant checks now being carried out. Sufficient staff were deployed to meet the persons assessed needs.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

The person experienced medication being administered in a caring way. A relative told us they felt staff knew how to support their loved one with their medicines. They told us, “We haven’t had any problems with medication, it’s been fine.”

Staff were confident in their ability to administer medicines safely and felt they had received the training they required. Staff said, “First we do the training and then we have the (competency) assessment. Then we can administer medication.”

Observations identified the person was supported with their medicines in a caring and supportive way. We observed staff involving the person in the process ensuring they felt comfortable.

Effective processes were in place and followed for the person to receive their medicines safely.. Medicines were safely stored and administered by competent staff. Regular stock and systems checks were completed, and medicines records contained the required information in relation to people’s needs.