Pendle Support Limited was rated Requires Improvement overall at its November 2023 inspection, with regulatory breaches found in medicines management (Regulation 12) and governance (Regulation 17). The service demonstrated strengths in caring, person-centred practice and staff training, but failed to maintain effective medication records, audit systems, and regular staff supervision and communication.
Concerns (9)
critical
Medication management
: “The stock of the medicines was not always accurately recorded. Therefore, we could not be assured the correct amount of medicine was in stock.”
criticalMedication management: “Liquid medication was not always dated when opened. This meant people could be receiving medicines which had been opened past the recommended guidelines.”
criticalGovernance: “Auditing tools were not always in place. Where audits were in place, they had not identified the concerns found during the inspection process.”
criticalGovernance: “The provider had failed to operate effective systems to assess, monitor and improve the quality of the service. This was a breach of regulation 17.”
moderateMedication management: “Records to support staff to apply topical creams were not in place and there was no body map to identify where the cream should be applied.”
moderateSupervision / appraisal: “Some staff told us they had not received a supervision in some time. Where staff had received a supervision, this was over the phone rather than face to face.”
moderateIncident learning: “Lessons learnt took place following on from an incident. However, the records were not always updated to reflect this.”
minorEnd-of-life care: “Staff had not had training in this area. This meant if a person's health deteriorated, staff may not be trained to accommodate this.”
minorStaffing levels: “Staffing is like a roundabout, with sickness and moving staff around... This can cause stress to service users as they think one person is coming and it is another person.”
Strengths
· Staff had received induction, training and support needed to carry out their role with high training completion rates.
· People were supported to have maximum choice and control of their lives in the least restrictive way possible.
· Recruitment processes were safe with all required checks including DBS undertaken prior to employment.
· People and relatives spoke positively about the registered manager, describing them as approachable, understanding and supportive.
· IPC practices were safe with plentiful PPE supplies and person-centred approaches to PPE preferences.
Quality-Statement breakdown (21)
safe: Using medicines safelyRequires improvement
safe: Assessing risk, safety monitoring and management; Learning lessons when things go wrongRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Preventing and controlling infectionGood
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: End of life care and supportRequires improvement
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: Improving care quality in response to complaints or concernsGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirements; Continuous learning and improving careRequires improvement
well-led: Engaging and involving people using the service, the public and staffRequires improvement
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