Tameside Learning Disability Service was rated Good overall following a January 2024 inspection of this domiciliary and supported living service supporting 58 people with learning disabilities and autism. A recommendation was made regarding medicines management (when-required protocols and MAR completeness), and minor governance gaps were identified around CQC notifications and provider registration accuracy, but no regulatory breaches were found.
Concerns (5)
moderate
Medication management
: “Guidance for 'when required medicines' was not always person centred. This needs to be updated to allow staff to be able to administer the medicines when appropriate.”
moderateMedication management: “Medicines Administration Records (MARs) need to be updated for some medicines that were handwritten to include extra instructions on how to give service users medicines safely.”
moderateStaff competency: “A competency framework needed to be introduced, in order to assure the provider that staff had the appropriate competency levels [for PEG support].”
moderateGovernance: “We found a small number of safeguarding incidents had not been submitted to CQC by the registered persons.”
moderateGovernance: “The provider needed to ensure their current registration reflected the services they were delivering to people.”
Strengths
· People were involved in their care planning and support was adapted to changing needs, with care plans described as truly person-centred.
· Sufficient staffing levels with low turnover; relatives noted consistent, familiar staff who knew people well.
· Staff received comprehensive training including specialist areas such as diabetes and dementia awareness.
· Strong promotion of independence, including a 'my house my home' initiative to keep people in their local community.
· Effective partnership working with health and social care professionals, including hospital passports and supported appointments.
Quality-Statement breakdown (24)
safe: Using medicines safelyGood
safe: Systems and processes to safeguard people from the risk of abuse and avoidable harmGood
safe: Assessing risk, safety monitoring and managementGood
safe: Staffing and recruitmentGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Staff support: induction, training, skills and experienceGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesGood
responsive: Meeting people's communication needsGood
responsive: Supporting people to develop and maintain relationships to avoid social isolationGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: How the provider understands and acts on the duty of candourGood
well-led: Engaging and involving people using the service, the public and staff; Continuous learning and improving careGood