Two more updates on social care for learning disabled and/or autistic people that CQC have recently rated inadequate. You can see all the reports on the Curated Content section of my site here, if you’d like to just go straight to the relevant CQC information without my commentary.
First up today, Heathcotes Yorkshire Supported Living, based in York. The colour of this report automatically triggers a sinking feeling in the pit of my stomach. All those red dots.
Some of you might be surprised that CQC are inspected Supported Living services. Or not, but Supported Living is not routinely inspected or regulated. CQC only regulate where a regulated activity, such as providing personal care, is provided:
Heathcotes Yorkshire Supported Living Office provides care and support to people living in six ‘supported living’ settings, so that they can live in their own homes as independently as possible. The service supports people with a learning or physical disability, autism or mental health needs.
Not everyone who used the service received personal care. The Care Quality Commission (CQC) only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do, we also consider any wider social care provided.
At the time of inspection, the service was supporting eight people with a regulated activity across two of the supported living settings.
So what did CQC find? The promise of Supported Living was always increased choice and control, people (in theory) choose their accommodation provider and their care provider and aren’t tied into receiving both from the same place or person. This Supported Living service was, as CQC put it, meant to support people to live as independently as possible.
What was the reality in the two settings they inspected?
The care provided did not maximise people’s choice, control and independence.
Support provided did not always promote daily living skills and access to a range of activities and events.
Outcomes for people were not always positive.
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.
The increased independence dream was a false start then. Surely at least people were safe?
People did not always receive safe care as staff were not always provided with the correct skills or were suitably deployed to meet the needs of people.
Good practice guidance and organisational policies were not always consistently followed.
Oversight of the supported living services was inconsistent.
That wasn’t guaranteed either. What about the ethos and values, the culture. How did it feel to live there?
The ethos, values, attitudes and behaviours of leaders and care staff did not ensure people using services led confident, inclusive and empowered lives.
Relatives spoke negatively about the culture of the service and felt unable to approach management with their concerns. Relatives felt the inconsistency of a management team within the service had impacted negatively on the service.
You know it’s bad when the relatives say it’s bad. For more on that see the next example below.
A year ago CQC inspected and rated this service as good. It has sunk from good to inadequate within the space of 12 months.
The inspection was prompted in part due to concerns received about the safety of care received in one ‘supported living’ setting. A decision was made for us to inspect and examine those risks.
And sunk quite spectacularly:
We have identified breaches in relation to safeguarding, systems and processes, medicines, infection control, staff training and support and quality assurance. We have also made recommendations in relation to the principles of the MCA, dealing with complaints and supporting people to have a healthy diet.
The first finding is that there was no registered manager in post.
This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.
The provider had warning that the inspection was going to take place:
We gave the service short notice of the inspection because some of the people using it could not consent to a home visit from an inspector. This meant that we had to arrange for a ‘best interests’ decision about this.
12 months ago this Supported Living service was rated good for safety. I’ve said before, and no doubt I’ll say again, but good in CQC speak just means that basic standards are met. To have anything above basic standards you’d be looking at outstanding. Then there’s requires improvement and ultimately inadequate, the lowest rating of the low.
A year on from being considered good, they are now considered inadequate.
This meant people were not safe and were at risk of avoidable harm. People were not always kept safe from avoidable harm because staff did not always know people well and how to protect people from abuse. The provider did not always follow appropriate processes to safeguard people from risk of harm.
Safeguarding concerns were not always investigated, and actions were not always implemented in a timely manner. This put people at possible risk of abuse or neglect.
Some staff had not completed their safeguarding training and some required refresher training. Staff said they felt able to raise safeguarding concerns however, staff had not raised concerns regarding issues found during this inspection.
Restrictions were placed on some people without the lawful authority to do so. We observed people having to knock to get out of their flat and go in to the communal area.
The provider had policies and procedures to deal with allegations of abuse, but staff did not follow these consistently.
A failure to ensure systems and processes were in place to protect people from abuse was a breach of Regulation 13 (Safeguarding service users from abuse and improper treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
So not only can the place not guarantee that people will be kept safe from abuse, neglect and harm, but it is also a free for all when it comes to implementing policies and procedures put in place to deal with any concerns that were raised. Add to that people being kept under lock and key, like caged animals really. Can you imagine having to knock to leave your home, and enter a shared area? Where else would this be considered acceptable? You’re keeping someone prisoner, holding them hostage. With no authorisation from the Court of Protection to do so.
What about people who who needed support with medication?
Medicines were not managed safely… We found that when people had been prescribed PRN medicines these had not been administered in line with the prescriber’s instructions. This resulted in poor outcomes for people. We could not always be assured that staff understood and consistently implemented the principles of STOMP (stopping overmedication of people with a learning disability, autism of both.)
In other words, CQC could not be confident that people living there weren’t subject to being over medicated, no doubt with sedatives. Chemical restraint really. I mean if you’re locking people in their flats, why not give them a little more anxiety medication than they need to keep them quiet, and it easier on the staff.
This was a breach of Regulation 12 (Safe care and treatment). There was a further breach relating to failure to protect people from the risk of infection. Staff weren’t wearing appropriate PPE in line with government guidance, I mean they’ve only had two years to get it right.
Staff also weren’t ensuring that people received support to live in a safe, clean environment, that didn’t stink.
When people required support with their cleaning the provider did not have robust cleaning schedules in place at one ‘supported living’ service to support people to live in a safe and clean environment.
There were no checks of the environment to ensure standards of cleanliness were maintained to a high standard.
During inspection, we found dirty toilets, dirty and damaged flooring, holes in walls, damaged furniture and we noted malodours in some people’s homes.
Whilst some of these concerns had been reported to the landlord for actioning, the provider had failed to assess how to ensure infection control was to be safely promoted in these areas.
Furniture was damaged in communal areas and the laundry room was disorganised and chaotic. This increased the risk of infection.
Inspectors highlighted numerous concerns relating to the assessing, monitoring and managing of risk. They also had concerns about staffing, another breach in regulations.
The service did not always have enough correctly trained staff, to safely support people.
Staffing levels were not always arranged in line with people’s support needs. Trained staff were not always deployed according to peoples’ care plan requirements.
For example, one person had specific needs which required staff to have training to keep the person safe when they were distressed. On the day of our visit, there were not enough trained staff deployed to work with the person to keep them and others around them safe.
Moving on to effectiveness, inspectors found “widespread and significant shortfalls in people’s care, support and outcomes” and again, the service rating dropped from good to inadequate.
Staff weren’t suitably, or adequately, trained. Some staff had received no learning disability awareness training despite their roles being to support learning disabled people. Staff and people they were supporting were both at risk due to insufficiency of staff skills, “some staff were supporting people with complex needs with minimal training“. It will come as no surprise that appraisal and supervision was not provided in line with the provider’s policy.
Inspectors found that the principles of the Mental Capacity Act were not always being followed, and people were not always supported in the least restrictive way possible. They found that care plans were in the process of being updated…. always being updated, never freshly updated, personalised and brilliant.
One ‘supported living’ service did not always ensure that people were provided with joined-up support so they could travel, access health centres, education and or employment opportunities and social events.
One relative told us “[Family member’s] life has become significantly smaller since living there, they can no longer do the things they used to enjoy doing and have lost a lot of skills.”
21st Century Care and Support, shrinking lives, aspirations, hopes and dreams, for profit.
The culture here is clearly crook, as reflected in the rating for caring, which now requires improvement, another drop from good.
Relatives told us communication between management and relatives was poor. Relatives stated this was often to do with the regular change in management.
People were not always asked their views or wishes regarding their care. Care was delivered to some people to reduce risk to staff instead of people’s choice.
All about the staff. Who seem to think that this place exists for them, not the residents. Unsurprisingly this resulted in people’s privacy and dignity not always being respected:
Staff did not always knock on people’s doors and ask permission to enter before entering people’s homes.
People did not have the opportunity to try new experiences, develop new skills and gain independence.
People were not always treated with compassion. On one occasion, staff had failed to follow a person’s care plan which had been developed to support the person, when they were feeling unwell.
Feedback from relatives was negative at one service. One relative said, “Staff just do not care about people in the service, [family member’s] flat is dirty and food is mouldy and out of date. I don’t think staff have the training or support to be able to care for people with complex needs, they don’t support them with the things they need. I don’t think staff respect us or [family member] at all.”
We observed some meaningful communication between staff and people using the service. People told us they were happy living there and that staff were caring.
Arrrggghhhh, the formulaic CQC report strikes again.
‘Some meaningful communication’ and people said they were happy… mouldy food, stinking flats, dirty toilets, not seeking medical attention when required, a lack of compassion, staff coming and going as they like, not knocking on your door. But ‘some meaningful communication’.
Not to mention the point of Supported Living is meant to be to enable someone to live as independently as possible. How does that square with: “People did not have the opportunity to try new experiences, develop new skills and gain independence“?
Responsiveness had also dropped from good to inadequate. Staff didn’t have up to date, accurate information or care plans to provide personalised care and support. Where plans were in place, they weren’t routinely followed. This was another breach in regulation, this time Regulation 9 (person-centred care).
People were not always actively supported to follow their interests or encouraged to take part in social activities. One relative told us “[Family member] does not go out or do anything anymore. They are not encouraged to go out and often just stay in their flat and in bed. They have no stimulation and have declined so much.”
A non-life. Worse than just a non-life, a shrinking life.
The final domain that CQC inspect and rate is whether the service is well-led. Again, rated good 12 months earlier, it is now inadequate.
Governance processes were inconsistent and ineffective and failed to hold staff to account, keep people safe, protect people’s rights and provide good quality care and support. Oversight of one ‘supported living’ service was poor, good practice guidance was not consistently applied and organisational procedures were not followed.
Some quality assurance processes were operated, but they did not identify concerns we found. The lack of robust systems and processes in place to identify concerns or shortfalls within the service placed people at increased risk of harm. For example, lack of staff training relating to restraint and failure to ensure appropriate infection prevention control measures were in place.
The medicines policy was not always followed by staff and the provider had not identified this.
The provider failed to ensure there was effective and competent management arrangements in place. Findings showed that there had been a lack of improvement at the service. Actions identified in the providers action plan had not always been achieved. This had placed people at significant risk of harm.
The failure to operate robust quality assurance and safety monitoring systems was a breach of Regulation 17 (Good governance) of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Inspectors highlighted failings related to culture, record keeping, and learning when things had gone wrong.
A culture of high quality, person-centred care which valued and respected people’s rights was not embedded within the service. Managers did not always set a culture that valued reflection, learning and improvement. Managers and staff did not always put people’s needs and wishes at the heart of everything they did.
It’s unclear to me how something so poor, such apathetic and indifferent care, such a rotten culture, an inappropriate value base that centres staff first and foremost can be improved in a sustainable way, but now they are in special measures they have a year to get out of them.
To finish today, Avalon Care Home which is registered to K Jones and R Brown. I have already highlighted this report on Twitter but repeat it here for completeness (am hoping to cover all November reports) but also because its a newly issued report, updated with enforcement action taken by CQC.
It’s described as follows:
Avalon Care Home is a residential care home providing personal care for up to 26 people. The service is registered to provide support to people living with dementia, people with a learning disability or autistic spectrum disorder, people with mental health needs, people with a physical disability and or sensory impairment, and younger adults. There were 23 people living at the care home at the time of the inspection.
That is a large home. Can you imagine sharing your home with 25 others and seemingly the only common factor amongst you all is that you require care or support?
The report states that the home has two floors and they “are adapting the ground floor to become a communal area for younger people and people with a learning disability“. There are always planned adaptations, reported in so many CQC reports. I can’t actually remember a report that stated ‘the home had recently been refurbished from top to bottom and everyone was receiving safe care in a clean, well suited environment’ but the number that have plans or adaptations apparently in hand is astounding.
What else did the inspectors find?
During the inspection we found that people did not always receive safe care and treatment.
Clinical risks to people were not always assessed or monitored and people did not always receive their medicines safely.
Records did not adequately guide staff on what actions to take.
Staff shared safeguarding concerns with the local authority although their processes for monitoring this required improvement.
There were cleaning schedules in place although some areas were cluttered.
People told us they felt well cared for living at the home. A relative said, “I feel that my relative gets safe care.” We made recommendations about the safeguarding processes and learning lessons if things go wrong.
One of the most frightening aspects of reporting these CQC reports in recent months has been the huge disconnect between what relatives report/see/believe and the quality, and perhaps more importantly, safety, of what is on offer when CQC visit.
I’m left wondering whether relatives truly don’t know any different? Whether their own expectations are so low, perhaps accompanied by the lack of availability of positive alternatives, that they really believe these places that CQC are identifying as inadequate are good. I honestly don’t know.
Although staff training was up to date, further training in managing clinical needs was required, which we have made a recommendation about.
People were not always supported to give consent about their care and treatment in a lawful way.
Although people had access to healthcare facilities, staff did not always involve external professionals to make sure people’s care and treatment was co-ordinated and consistent.
The provider did not make sure there was effective governance to protect people from risks and promote safe and high-quality care.
Managers did not always identify problems or concerns and therefore they missed opportunities to improve the safety of care and treatment people received.
Another concern, training tickboxes all ticked, but practice not up to scratch. Obviously training can play an important role but there appears no guarantee that doing training leads to improved practice, especially if the culture is poor and there’s an absence of leadership or management support.
The language of CQC reports are always so positive. That line, ‘people had access to healthcare facilities’ which could simply translate to ‘people were registered with a GP’ but then the second half ‘staff did not always involve external professionals’… what’s the point in having access to something, that staff then don’t support you to use?
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; the policies and systems in the service did not support this practice.
Although we found gaps in the support and culture, staff were very caring in nature and upheld people’s dignity and privacy. Care plans were written respectfully and put the person at the centre.
Although staff and managers had values to support people to lead confident and inclusive lives, the environment of the home made this difficult.
Younger people who had a learning disability lived within a care home environment, meaning opportunities for choice and control were limited. It was difficult for staff to meet the needs of everyone, due to a wide range of service user groups, with different sets of guidance for staff to follow.
Although is doing some heavy lifting in this report. It’s great that staff are caring, but that alone doesn’t support someone to live a life. Later in the report CQC inspectors share that these well meaning and caring staff, were putting people’s lives at risk…. and management had to failed to prevent that, or notice it:
Staff did not complete robust assessments about the risks to people’s health and did not always recognise when further medical input was required.
For example, staff failed to recognise when a person was at risk of dysphagia and did not request a specialist assessment to make sure the person received appropriate treatment.
Dysphagia means when someone has difficulty swallowing certain foods. People at risk of dysphagia require specialist assessments to determine how the risks should be managed to minimise the risk of choking.
This meant there was a risk to the person’s health and safety.
CQC identified breaches in relation to medicines management, managing risk, consent to care and treatment and the overall governance of the service. Some of these breaches were prolonged breaches, having been identified at a previous inspection and promises made that things would improve. There were numerous failings of management by the registered manager and the provider.
CQC issued a warning notice against the registered manager and provider.