Turning Point - Pendlebury House

Updated 27 September 2022

Turning Point Pendlebury House is a mental health rehabilitation service for people with enduring mental health problems who have been assessed as having the potential to improve their level of functioning and independence. It is a 10-bedded facility for males and females over the age of 18. The service previously admitted male patients only. This was changed in 2020 as the service had identified that the hospital was often not at capacity and there was an identified need in the local area for more female rehabilitation beds.

There was a registered manager at the time of our inspection and had an identified controlled drugs accountable officer.

Turning Point Pendlebury House is registered for the following regulated activities:

• Treatment of disease, disorder or injury
• Assessment or medical treatment for persons detained under the 1983 Act.

Turning Point Pendlebury House has been registered with CQC since 08 February 2011. There have been three previous inspections carried out at Pendlebury House; the most recent was conducted on 11 April 2016. Pendlebury House was rated as outstanding overall at the 2016 inspection. The caring and responsive domains were rated outstanding with the other three domains rated as good.

The most recent Mental Health Act Monitoring visit was on 20 March 2019. At that visit, we found good adherence to the Mental Health Act and Mental Health Act code of practice with no issues raised.

We undertook this inspection as part of a random selection of services rated good and outstanding to test the reliability of our new monitoring approach. This inspection was focused on the safe and well-led key questions. The effective, caring and responsive key questions were not inspected and so the ratings for those key questions remain the same.

What people who use the service say

We spoke with three of the nine patients at Pendlebury House on the day of our inspection and observed interactions between staff and patients. Patients gave positive feedback about the service and the care and treatment that they received from staff. Patients felt safe on the unit and described the atmosphere as being calm and laid back. Patients described staff as being respectful and noted that staff were always approachable and friendly. Patients felt that there were enough activities that took place and that staff kept their family and carers involved in their care and treatment.

Updated 27 September 2022

We undertook an inspection of Turning Point – Pendlebury House as part of a random selection of services rated good and outstanding to test the reliability of our new monitoring approach. We only looked at two of our key questions; how safe and how well-led is the service?

Following this inspection our rating of safe, well-led and the overall rating of this location went down. We rated it as requires improvement because:

• Areas of the environment were dated and in need of refurbishment. These areas included the rehabilitation kitchen, communal bathroom and the ensuite patient bathrooms. The fire doors had also been identified by the service for replacement, but this had not yet been completed. The service did not have a specific maintenance or refurbishment plan, although managers had identified areas of the hospital that they felt needed refurbishment. The service also had maintenance jobs that were pending and had not yet been completed.
• The service’s processes for reviewing and monitoring the environment and maintenance were not always completed in line with the provider’s expectations. There were gaps in some of the weekly environmental checks for the service. It was also not clear that these processes identified every issue or how issues identified in these audits were monitored to ensure they were addressed in a timely manner. The processes did not ensure that managers had appropriate oversight of all the identified issues and how they were being monitored and addressed.
• The hospital’s governance processes and checks had not ensured that all issues in the service were identified and addressed. There were out of date items in one of the first aid kits. One of four risk assessments checked had not been reviewed in line with the provider’s expectations. Two of the five prescription cards checked had missed signatures for medication. The service had written a recent police incident notification form but had not submitted it to CQC. All staff were not aware of the location of the ligature cutters in the hospital. The service had some low compliance rates for mandatory training courses.

However:

• The service provided safe care. Staff generally assessed and managed risk well. They minimised the use of restrictive practices and followed good practice with respect to safeguarding.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. Patients gave positive feedback about the service, staff and management.
• Despite recent challenges in respect of staffing and vacancies in the service, staff and managers were passionate about their jobs and attempted to limit the impact on the care and treatment of patients.

Updated 27 September 2022

Our rating of this service went down. We rated it as requires improvement. See the summary above for details.