This is the first blog post reporting on the detail of Care Quality Commission reports finding inadequate care, that I’ve written, rather than sharing the information on Twitter. Consider it a little experimental, I’m going to pick and choose what to highlight and would welcome feedback on whether its useful. Given the number of reports to be covered I’ll not provide a comprehensive overview of each report, but snippets and a link back to the provider’s page on the CQC website so you can access the complete report if you so wish.
First up, The Phoenix in Lincoln which is run by Linkage Community Trust.
The Phoenix is a residential care home providing personal care to up to maximum of six people. The service provides support to people living with learning disabilities and autism. At the time of our inspection there were six people using the service.
When inspecting care for learning disabled and autistic people CQC assess whether providers are following the ‘Right support, right care, right culture’ guidance.
People were not always supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests. Care records we reviewed stated people living at the service did not always feel safe, due to other people being distressed. Incidents and accidents were not always effectively recorded. There were inconsistencies in people’s care records when incidents had occurred, making the monitoring and management oversight of incidents ineffective. Senior management were developing systems to improve this process. Since the inspection these new processes have been implemented.
Here’s the deal, if people don’t feel safe in their own home, it’s not ok. If people don’t feel safe because some of their house mates are distressed, it’s not ok, for the person or their house mate.
Risks associated with people’s care needs were not always identified and acted on in a timely manner. Risk assessments and care records were not always updated effectively.
The management team had identified issues with risk assessments prior to the inspection and were working on an action plan.
Always an action plan and a promised bright new future.
People’s medicines were not managed safely in line with national guidance. Medicine administration records (MARs) did not always give staff the information needed regarding the route in which medicines should be administered. Information on how people would like to receive their medicines was not detailed or personalised. The management team said that they would act on our findings and changes would be made to the MARs on the next medicine’s cycle, this would be achieved with support from the GP and pharmacy.
According to their website Linkage have been providing residential care for learning disabled people since 1992, they have 24 residential care properties, supported living and community services.
Thirty years, but no effective system in place for delivering and administering medication.
Areas of the home needed maintenance. An outside decking area needed repair which mean people could not use the outside space. Cleaning schedules had not been completed by staff. Areas of the home required cleaning. Staff did not always wear face masks in accordance with government guidance.
Thirty years, but people are living in an unclean home.
People’s care records did not always promote their care being delivered in a person-centred way. There were improvements needed to the language used in people’s care records to ensure they were treated with respect and dignity.
People’s care records did not always reflect their needs and wishes. The management team had identified issues with care plans prior to the inspection and were working on an action plan.
We observed staff interacting with people in a kind and caring manor.
Another promised action plan…. with language that sounds like it was left over from thirty years ago.
The COVID 19 pandemic had a negative impact on staffing and the provider continued to work to address this. They had worked to restructure the service to ensure people were supported by staff who knew and understood them well. They were responsive, supporting people’s aspirations to live a quality life of their choosing.
Although there had been many anonymous whistle blowers about the service. Concerns were investigated by the provider and their quality monitoring team.
The inspection was prompted in part due to concerns received about allegations of abuse, staffing and management culture. A decision was made for us to inspect and examine those risks. As a result, we undertook a focused inspection to review the key questions of Safe, Effective and Well-led only.
The overall rating for the service has changed from good to inadequate based on the findings of this inspection.
Hmmmm. Many anonymous whistleblowers is concerning. I can’t cover the whole report so will just look at whether they’re following the law. Turns out they aren’t working in line with the law, notably the Mental Capacity Act and Deprivation of Liberty Safeguards:
There was a lack of understanding by staff and the management team regarding MCA and DoLS.
The registered manager and deputy manager had not identified that some people living at the service required a DoLS authorisation to be in place. This placed people at risk of being unlawfully deprived of their liberty.
There was only one person who did not require a DoLS in place. However, out of the other six people there was only one person who had an up to date DoLS authorisation. One person had been living at the service for other a year. A DoLS authorisation had only been applied for once they had left the service without supervision.
The provider did not always identify and assess people in order to apply for a DOLS authorisation, this is a breach of Regulation 13 (5) Safeguarding (DoLS) of Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Next up, Forge House Services Ltd in Cullompton, Devon.
Forge House is a residential care home that “specialises in the care of people who have a learning disability“. They are registered for up to 11 people and at the time of the inspection there were 9 people living there. Right at the beginning of the report a caveat is provided: “People lived in a service impacted by the death of a long-standing member of the management team. People and staff were being supported with this“.
Caveats aside, what is it like if Forge House is your home?
People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.
Where people lacked capacity to make decisions, the provider failed to put in place documents to support decision making. Not all restrictions were considered when looking at the least restrictive options for individual people. Some internal doors were kept locked to all people without considering how the risks for each individual person could be safely supported.
People did not have outcome focused support plans. People were not supported to agree plans with clear steps that would support them to develop skills and interests or support their sensory needs to enable people to cope with their environment.
People were not always enabled to access specialist health and social care support where appropriate. Staff did not always support people to lead decisions about their own health.
Risk management was poor. A lack of support plans and assessments in place meant people’s needs were not identified, assessed or managed effectively. Staff were not provided with enough clear guidance to support people safely. A failure to monitor incidents meant there were missed opportunities to avoid and reduce reoccurrence.
Care was not always person-centred or designed to promote people’s dignity, privacy and human rights. People’s care and support plans did not reflect people’s individual needs and aspirations. People’s strengths, levels of independence and quality of life was not always accounted for when planning and reviewing their care, and people were not involved in this process. People’s care and support did not consistently focus on their quality of life or follow best practice.
This is beyond shocking. If you’re not supporting people to have choice and control in their lives, to take decisions about their health, if your risk management is poor, if you’re not focusing on people’s quality of life or best practices, what are you doing exactly?
People were not provided with opportunities to try new activities tailored to them that enhanced and enriched their lives. We observed people participated in group activities facilitated within the home rather than pursuing their own individual interests or seeking opportunities for volunteering or employment.
People were not always protected by a service that had safeguarding systems in place to report and respond to accidents and incidents. We found instances where safeguarding concerns had not been reported to CQC, or local safeguarding authorities. Leadership was not effective and did not identify that people were put at risk or subject to potential abuse.
There was a core team of staff who knew people’s needs and were kind and caring.
I struggle with the CQC report writing process when statements like this are made. These are people warehoused in the community, living non-lives, leadership is ineffective, people at risk and potentially subject to abuse, but the core team of staff were kind and caring…. how can you be kind and caring and that utterly inept at your job?
People did not lead inclusive and empowered lives because the ethos, values, attitudes and behaviours of the management and staff did not promote this. People were supported by staff who did not understand best practice in relation to the wide range of strengths, impairments or sensitivities people with a learning disability and/or autistic people may have. This meant people did not receive empowering care that was tailored to their needs.
There were indicators of a closed culture. There was a failure to identify and mitigate institutionalised practices and risks associated with closed cultures so that people received support based on transparency, respect and inclusivity. A number of restrictive practices were found, and the routines within the home were not always personalised to individual people. The service had not been supported by the provider to ensure they were aware of and implementing current best practice and guidelines.
Staff had not placed people’s wishes, needs and rights at the heart of everything they did. There was a lack of information about preferences to support people with these. People were not always involved in planning their care. People were not leading inclusive and empowered lives.
Non-lives, closed cultures, institutional practices, restrictive practices, focused on staff not people. But, core team were kind and caring. Just doesn’t sit well with me.
The provider failed to ensure staff received appropriate training and support to understand people’s individual needs and provide enabling support to people. The support people received was not in line with current best practice guidelines.
Risk assessments in place were not encouraging positive risk taking for people, were not evaluated and measured at regular intervals to assess their effectiveness.
The provider failed to develop effective governance and quality assurance system to assess the quality and safety of the support people received. There were a lack of audits and actions taken when things went wrong. Actions were not always documented, and it was unclear if actions were completed. This meant improvements were not always made to improve the care people received.
There were minimal internal quality assurance systems and processes to audit or review service performance and the safety and quality of care. Where checks and audits were carried out, they had not always identified or prevented issues occurring or continuing at the service. Where issues had been identified, the registered manager and provider had not always ensured actions were taken to maintain, or improve the quality and safety of the support being delivered at the service.
Unsurprisingly, the service has been found in breach of regulations, the law, on multiple occasions in this inspection alone.
We have found evidence that the provider needs to make improvements. Breaches of legal requirements were found in relation to providing safe care to people, premises, recruitment, staff training, person centred care, safeguarding, consent to care, dignity and respect and good governance.
Just a few snippets, lowlights, from the report.
Safeguarding incidents were not always reported to the local authority. We saw records where a person had choked due to staff not following their choking risk assessment. Although this had been reported to the registered manager, and a review by a speech and language therapist requested, no further investigation had taken place to understand why the incident had happened. Another person had an unexplained bruise. This was reported as an incident but there was no investigation in to how it occurred, and it was not reported to the local safeguarding authority. Other incidents where people physically hurt others were also not reported. This lack of reporting, and investigation meant people were at risk of recurring harm.
We know learning disabled people die decades prematurely, from entirely preventable causes, such as choking and aspiration. Here we have a person, identified as being at heightened risk (in a choking risk assessment), staff ignore the recommendations for supporting the person, they choke, staff reported it to the manager, and nothing happens. Just pass the person on to speech and language therapy and carry on regardless. Don’t conduct any review in the meantime, don’t provide any additional instruction to the staff who weren’t following the existing assessment. Don’t do anything to keep this person safe.
Another person with an unexplained bruise. Report the bruise but don’t bother investigating how they got the bruise. How can this be allowed? Don’t report it to the local safeguarding authorities as you’re required to do.
This casual apathy leaves people at increased risk of abuse and harm, and in some cases premature, preventable death. As does unauthorised restraint, which in any other environment would be called what it is, assault.
Some people in the home could harm themselves or others when they were distressed. Staff were not trained to use physical interventions, using the safest and least restrictive methods, as outlined in people’s support plans. This meant the provider failed to ensure staff knew how to safely support people.
Inconsistent support was being provided that was not in line with behaviour support plans. This included staff using restraint that was not in line with a person’s physical intervention plan.
In February 2022 an ‘Incident Requiring Physical Intervention Reporting Form’ had been completed. A person had been restrained and their physical intervention plan not followed. The manager’s part of the form was not completed or signed, and there was no evidence the incident had been reviewed.
So much so that even when CQC inspectors were in the home, inspecting, staff didn’t have the sense to up their game:
During the inspection risk assessments were not followed. For example, one person’s choking risk assessment stated a staff member needed to be sat with the person during mealtimes encouraging the person to eat at a reasonable speed. During the inspection, it was observed that whilst this person was eating, the staff member was sat writing notes and not supporting the person. The registered manager was informed of this.
Later on there’s another one of those what I’d consider to be questionable, or just inconsistent CQC judgements. The inspectors pass comment on a pretty grim sounding bathroom:
We were not assured that the provider was promoting safety through the layout and hygiene practices of the home. Some areas in the home were not clean, for example a step in the communal bathroom downstairs was covered in grime and the handrails next to the toilet were rusty and could not be cleaned effectively. This was pointed out to the registered manager on the first day of the inspection and was found to still be the same on the second day of the inspection. This presented an infection control risk.
A grimy step in the bathroom, not cleaned by the second day of inspection, which took place over two weeks later. The report also references that an Environmental Health Officer visited the home while CQC were inspecting, and wait for it, suggests that the management team were responsive:
During the inspection, the management team were responsive and started to address the issues identified
by the EHO.
Over a fortnight to clean a step in the bathroom, still not done, but management team were responsive. I despair.
The final lowlight I’ll share with you is the classic indicator of a closed culture, with a focus on staff and not the residents who’s home this is:
One toilet within the home was locked and had signs on it saying, ‘for staff use only’. The registered manager was unclear as to the reason for this. Making unrequired restrictions such as having a locked toilet in people’s homes is contrary to the principles of the MCA. This practice also promoted a culture of inequality and did not value people or their home.
Forge House Services have been issued with a number of warning notices and they have to produce another action plan. Can’t help feeling this is quite a relaxed approach to inadequate care. Will share more another time.