Pendlebury Court Care Home

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

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to governance at the service.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. Staff practices were not always aligned with the provider's policies, values and expectations, resulting in variable experiences for people. Leaders had not always ensured that people were fully involved in decisions about their care and support, or that staff consistently delivered care in line with people's individual needs and preferences. Following the inspection, the provider shared actions they intended to take to address the concerns identified and improve outcomes for people.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation.Following our previous inspection, the provider submitted action plans setting out how they would address the concerns identified. However, at this inspection we found ongoing concerns relating to medicines management and governance, and the provider remained in breach of legal regulations. This demonstrated that leaders had not always been effective in embedding and sustaining the improvements required to ensure people consistently received safe, high-quality care and support.

The provider had not always created a culture where staff felt fully confident their concerns would be listened to and acted upon. Staff were not always assured their concerns would be acted upon. Staff understood the provider's procedures for speaking up and knew how to report concerns about people's care, safety or wellbeing. However, several staff told us issues they had raised had not always been listened to or acted upon. This meant staff were not always confident that raising concerns would lead to meaningful action or improvement. While systems were in place to encourage staff to speak up, these were not always effective in ensuring staff felt heard and valued.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. The provider demonstrated an understanding of staff's individual needs and had systems in place to support them in their roles. They also recognised the importance of maintaining an inclusive workplace and shared plans to further strengthen workforce development and support arrangements. Leaders promoted staff wellbeing and development through regular supervision, team meetings and training opportunities. Most staff told us they felt supported in their roles, and relatives spoke positively about the management of the service and communication from leaders. However, some staff told us concerns they had raised had not always been acted upon, which indicated staff experiences of leadership and responsiveness were not always consistent.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes. The provider had quality assurance systems in place to monitor some key areas of risk, including skin integrity, nutrition and hydration, weight loss and falls. However, these internal quality monitoring processes did not provide effective oversight across all areas of the service. For example, we found shortfalls relating to medicines management, the quality of staff interactions with people, and care records that were not always accurate, sufficiently detailed or reflective of people's current needs.

The provider's governance and quality assurance processes had failed to identify and address these concerns effectively. This meant the provider did not have effective oversight of the quality and safety of the service or that risks to people were being consistently identified and managed. While some improvements had been made since the last inspection, these had not been sufficient to address all of the concerns and the provider remained in breach of legal regulations.

The continued shortfalls demonstrated that the provider had not been effective in driving and sustaining the improvements needed to ensure people consistently received, safe, and compassionate care which upheld their dignity. Following our feedback, the provider submitted an action plan detailing the improvements they intended to make.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. The provider had developed links within the local community, including arranging visits from children from a local nursery, which provided opportunities for people to maintain links in their community. The provider also worked with external health and social care professionals and made appropriate referrals when people required additional assessment, advice or support.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people.

While some improvements had been made since the last inspection, these were not sufficient to address all of the concerns identified. The provider remained in breach of legal regulations, and people did not always receive care that was safe, caring or upheld their dignity. Although systems were effective in overseeing some areas of risk, they had not ensured consistent standards across the service. Further improvement was required to provide assurance that people consistently received safe, person-centred care which protected their dignity and wellbeing.