Pendleton Care Limited

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 good. At this assessment the rating has remained good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 71 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The management team and staff had a clear understanding of equality, diversity and human rights. Information in the services statement of purpose informed people of the service’s goals to enable people to access local community provisions and enable people to access and develop lifestyle pathways.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Senior leaders knew people well and visited their home on a regular basis. Where areas of improvement were identified, action was taken to fully understand the reasoning and to make improvements immediately. For example, areas of improvement identified during this assessment in relation to care planning records had been identified by senior leaders and action was being taken to make appropriate changes.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Regular meetings took place with staff and representatives of the provider to give opportunities to speak up.

The provider had introduced ‘The Lightbulb club’ for members of the organisation to share ideas and thoughts on how to enhance the service.

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. Policies, procedures and training were in place to promote a fair and equitable workplace free from bullying and harassment.

The provider had clear responsibilities, roles, systems of accountability and good governance. These were not always used to manage and deliver good quality, sustainable care, treatment and support. They did not always act on the best information about risk and oversight of records.

The provider had on-going monitoring systems in place. During the assessment process we identified areas of improvement needed in relation to records. For example, of improvement needed in relation to care planning, medicines and risk management records, as records failed to demonstrate the actual level of care and support people received. The provider had identified this and had active plans for staff responsible for the management of the records to further develop a person-centred approach.

Information showed that referrals of incidents and concerns had been made to the local authority when required. However, statutory notifications required to be sent to the Care Quality Commission had not consistently been submitted. This was raised with the provider who took immediate action to review their procedures.

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 service worked with people and local health and care agencies to promote the best outcomes for individuals.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The provider engaged with other agencies to develop the service provided for people. For example, training for managers relating to the health, wellbeing and inclusion within the workplace.

Formal learning reviews to enhance the service took place, for example, when it was identified that not all required statutory notification had been submitted to Care Quality Commission. Staff received specific training in relation to learning disability and autism within the standards set by The Oliver McGowan Code of Practice.