Penrith Drive

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We identified 1 breach of the legal regulations. The governance systems needed to be more robust to identify where improvements were needed to care provision and the environment as identified at the inspection to ensure the improvements were brought about in an effective and timely way. Several improvements had been made during the inspection; however these had not always been identified by the provider or registered manager. People, their relatives and staff were asked for their views and experiences of the service. Feedback was listened to and addressed. There was a compassionate management team who, with staff, worked to ensure good health outcomes for people in partnership with external professionals. Staff told us they felt supported by the management team.

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.

There were inconsistencies in the culture of the service. Although staff were able to tell us what the vision and culture for the service was, it was not what happened in practice. There was a normalisation of an environment which was refurbished below the required expectations. Staff, including the management team had stopped questioning the lack of timely repairs and started accepting this standard as normal.

Other aspects of the service were positive. Staff were open and friendly. We saw staff were respectful of people and person-centred practices. Staff were approachable and keen to talk about their work. Staff told us, “We are like a big family, I love my job.”

There was a lack of understanding about what the providers values meant in practice. Staff were able to tell us about the organisations values and information was readily available on their website. However, the values did not always translate to the care that was provided. The management team lacked insight into the impact of their behaviour on care staff. The acceptance of poor response times from the landlord for repairs, restrictive practice and documentation not always being up to date meant the staff also accepted that as their normal.

Other aspects were positive. Equality and diversity in the workplace was actively promoted and staff were able to give us some examples of where this had made a difference.

Staff were positive and supportive about the registered manager. Staff thought the registered manager was knowledgeable, personable and a good leader who put people at the heart of the of the service. They felt valued and listened to by the registered manager. We saw positive interactions and engagement between people, the registered manager, and staff. It was clear people felt relaxed in their company and were used to spending time with them. The care staff team knew people and their needs well.

The registered manager and deputy manager were always visible in the service and knew people well. They spoke highly of the staff team and of representatives of the provider. Though it was evident that the management team possessed the necessary abilities for the role, they failed to see the risks involved of having outdated care documentation. The registered manager informed us the staff team was qualified and knowledgeable and had a thorough understanding of the care needs of individuals; this demonstrated a lack of appreciation for the significance of correct and current records.

Staff knew what processes supported them to raise concerns within their organisation and with partners agencies. Staff told us they felt “Listened to and empowered to make suggestions.” Staff told us they always felt able to speak to any of the management team. Staff took part in individual supervision sessions and told us supervisions were helpful.

Processes were in place to enable staff the opportunity to speak up. There were regular staff meetings, supervision sessions and appraisal. These included open and honest feedback which led to improvements in care. Staff knew how to raise concerns to CQC and other organisations.

Staff uniqueness, diversity and ethnicity were embraced within the team. Staff told us their individuality was supported by the organisation, and they were treated fairly. Staff told us the shift pattern and the number of hours they worked suited them. One staff member said, “I am really happy with how I am treated and the working hours.”

The provider welcomed diversity in the workplace. Policies and procedures supported this. Relevant legislation and best practice guidance was implemented to ensure staff were treated in a fair and equitable manner. Recruitment processes supported fair employment opportunities.

Staff told us they were clear in their roles and responsibilities; they understood quality assurance processes and how they contributed to the quality of care people received. Care staff were positive about the support they received from the registered manager, and their management skills. The registered manager was open and honest during the inspection and discussed their frustration about environmental issues that had been reported to the landlord that had not yet been addressed. The registered manager took action to address the issues identified during the inspection.

The provider's processes for quality assurance and audits were not robustly applied. Quality assurance checks had failed to identify inconsistencies in information recorded in people’s care records including risk management plans. This meant that some information could not be relied upon as being accurate or up to date. They also failed to identify poor practice in relation to infection prevention and control and the environment. Action was taken during or immediately after the inspection to address most of the concerns found, however, this had not been identified prior to the inspection.

People were supported to access the community regularly if they chose to do so. People told us about activities they enjoyed, groups they participated in and friendship networks they had been supported to maintain.

The registered manager and staff worked in partnership with other professionals and community groups. They attended provider forums and registered manager network groups. Information was shared through team meetings. Staff told us they were proud of the relationships they had with people’s families and health care professionals. They told us communication was good, and they worked in partnership with each other.

Feedback received informed us the service worked in partnership with health and social care professionals. For example, working with deprivation of liberty assessors when applications were made to deprive a person of their liberty.

The service worked in partnership with other agencies. These included healthcare services as well as local community resources. Records showed that staff had contacted a range of health and social care professionals. This enabled people’s health and wellbeing needs to be assessed so they received the appropriate support to meet their continued needs.

Staff told us there were opportunities for learn from incidents or where things could have gone better. We were given examples of learning undertaken since the previous inspection. The registered manager gave examples of where staff had put forward improves or changes and these had been explored and put into practice.

Provider audits in place required strengthening to ensure services are robustly audited for the quality and safety of the care provided. There had been multiple opportunities for the concerns identified on this inspection to have been identified by the provider, however they had failed to do so.