I’ve not even opened this report yet but I’m feeling uneasy. In part due to the large number of red dots indicating the sheer state of the place, but also because Autism Anglia are a charitable provider. My recent post reviewing the November CQC data release found that if you were learning disabled or autistic and had care or support provided by a charity, it meant you were less likely to have good care (based on inspections in 2021 and 2022 to date).

So let’s take a look.

Lambert House is a care home for 11 autistic people. CQC describe it as:

The care home is a large two-storey building, with a communal bathroom and toilet on each floor. A communal lounge, dining room, recreation room and sensory room were located on the ground floor.

I’m already feeling pretty itchy about the idea of living with 10 other people. Last time I did that was as a student and my naive optimism of always having someone to chat with, gave way to a reality of 11 different people’s eccentricities, widely varying cleanliness and hygiene standards, vastly different tolerances and preferences for noise, TV channels and music, and so on and so on. I can’t ever imagine wanting to share my home with more than a small handful of select people ever again.

What did CQC find when comparing what was on offer to the ‘Right support, right care, right culture’ standards?

The model of care did not maximise people’s choice, control and independence. People were subject to restrictive practices without proper due regard to legal processes and requirements. 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. People were not supported to engage in activities that met all their needs. Some people living in the service had sensory loss but were not supported to engage in activities that met these needs. People were not always supported to communicate their wishes and feelings as there was limited use of communicate strategies.

I’m not even sure we can optimistically consider the above paragraph to relate to support. Imagine the misery of living in this sort of environment.

People were not supported in a manner which promoted their dignity, privacy and human rights. Some practices dehumanised people living in the service which was of significant concern. People were living in a poorly maintained and dirty environment which did not uphold their dignity. Safeguarding concerns had not always been shared in a timely manner. The support provided was not person-centred because staff did not follow risk assessments or care plans. This placed people at risk of harm. People were not supported by staff who knew them well due to the high use of agency staff and ineffective systems ensuring staff understood how to support people.

Warehoused. Dehumanised. Not communicated with or listened to.

We identified a closed culture in the service. A closed culture is ‘a poor culture that can lead to harm, including human rights breaches such as abuse’. In these services, people are more likely to be at risk of deliberate or unintentional harm. The provider had not taken effective action to identify and address the poor culture in the service. Leadership was weak and did not hold staff to high standards. Governance systems in the service were ineffective as they had failed to ensure regulatory requirements were met.

A culture that can lead to human rights breaches. A charity which claims on its website to:

offer personalised approaches that provide each individual with the necessary skills and strategies to enable them to realise their own strengths and abilities.

Weak leadership, poor standards, ineffective governance.

CQC conducted their unannounced inspection, in part in response to concerns that they’d received about how staff were treating people using the service, poor governance and restrictive practices (things like chemical or physical restraint, withholding people’s freedoms to move around, to eat or drink, to do as they wish in their own home, environments designed around staff not people, that sort of thing).

Three inspectors, a medicines inspector and an Expert by Experience conducted the inspection, visiting the service on three separate occasions.

In the last fortnight I’ve twice heard the suggestion that ‘most care is good’ and that ‘if CQC visit when they’re having a bad day then they can be rated harshly’.

This is so outrageously naive. A CQC inspection isn’t a one off snapshot of how a service is running on a single day. This is what happened for this inspection:

What we did before the inspection
The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used all this information to plan our inspection.

During the inspection
None of the people who used the service could speak with us verbally. We observed the care and support provided. We spoke with eight relatives about their experience of the care provided. We spoke with 12 members of staff including the registered manager, three interim managers, three agency staff members, three core staff members, the chief executive officer, and the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the registered provider. We reviewed a range of records. These included various care and support records for five people using the service. We reviewed all personal evacuation plans and deprivation of liberty applications. We looked at three staff files in relation to recruitment and three agency staff profiles. A variety of records relating to the management of the service, including audits and incidents were reviewed.

Due to the significant concerns identified during the inspection we met regularly with the provider, and professionals from the local authority and integrated care board to discuss and monitor the concerns identified.

This service is inadequate and now in special measures. They were rated inadequate in every domain other than responsiveness, which still required improvement (which means it’s not meeting minimum expected standards).

How unsafe do practices have to be to be rated inadequate? Let’s have a look at what the CQC team found at Lambert House. First up 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

Safeguarding concerns had not been shared in an appropriate and timely manner. This had impacted on the ability of the local authority to carry out their duties.

Restrictions on people’s movement and access to water had been implemented without proper and legal authority to do so.

We identified staff practices which were degrading to people living in the service and raised significant concern.

Next, a breach of Regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014

Risks to people’s safety were not managed effectively and this put people at risk of harm.

Some people living in the service were at risk of eating or drinking harmful substances. This risk was not managed. On one occasion we found a cleaning product, containing bleach, unsecured in a communal activity room without staff present. The ingestion of cleaning products was a known risk for some people living in the service. For another person we found their bedroom contained known items which the person was at risk of ingesting and could cause significant harm.

Risks to people were not monitored. One person had been identified as being of low weight however their weight records showed their weight was not regularly monitored. Their weight had been checked in February 2022 but not checked again till June 2022. At this point it was identified the person had lost 10lbs, despite this no further checks of the person’s weight had been taken by staff at the time of our inspection.

Two people living in the service had been assessed as being at risk of drinking excessively to such an extent that they could become unwell. Risk assessments specified their fluid intake should be monitored, however this was not taking place.

No bowel monitoring or associated care plans were in place this was despite known risks being identified regarding people’s bowel management.

There are many occasions where I struggle to remain professional. This is one of them.

How can they be so careless? So indifferent to people’s health and safety? Bleach lying around to be drunk. People at risk of malnutrition, fake monitoring/performative scrutiny of a four monthly weigh in and then no action taken. Not to mention what else could lead to sudden weight loss. People at risk of drinking excessively left to drink, people at risk from constipation with no monitoring.

We already know that learning disabled and autistic people are at increased risk of premature and preventable death. Real risk. The causes are known. Then ignored. Time and time and time again.

There was a further breach of Regulation 12 in relation to preventing and controlling infection:

We identified serious concerns in relation to the cleanliness of the environment.

Faeces was found around the communal toilet on the first floor on two of our visits. This included on the inside of the door handle and the flushing button. We observed people using this toilet with faeces present on both visits.

The water in toilets and accessible sinks had been switched off. Staff told us this was to manage the risk of people drinking excessively, however no consideration had been given to how this impacted good hand hygiene. No other measures, such as hand sanitiser, had been implemented.

The environment was not clean and, in some areas, posed significant infection control concerns. For example, we found the back of a chair next to a person’s bed had white mould growing on it.

Bedding and towels in people’s rooms were soiled.

Soft furnishing and seating were in poor condition with furniture padding exposed. This posed a risk as it was not protected and could not be easily cleaned.

The state of this place. Faeces around the toilet, and no water for people to wash their hands. Mould growing on the furniture, dirty bedding and towels, and broken furniture with holes in the covers. 11 people living in this state. Well, is it really living?

There was yet another breach of Regulation 12, in relation to using medicines safely. They couldn’t even get the basics right, such as people’s medicines stored in a box with their name on it – but one box had two different names on either end. There was no effective record keeping or oversight of medications, and medicine administration records (MAR) didn’t reflect all medicines that people had in place correctly. Wrong doses, changed administration timings.

These sorts of things should be picked up during auditing, if there was any effective governance in place. This is what CQC had to say about that:

Medicine audits had not been effective at identifying issues with medicines. For example, one person’s medicine records stated they had prescribed several “as required” medicines for constipation. Their medicine records showed there were being given several times a day. The registered manager told us these medicines had been changed to daily however the person’s records had not been updated to indicate this.

When medicines were prescribed as and when required (PRN), protocols were generic and did not provide person centred details to support staff when it was appropriate to administer. Some people had PRN protocols for medicines which they were no longer prescribed. The service did not regularly review PRN protocols so they did not reflect peoples needs correctly.

Care plans were difficult to understand and lacked key information about people’s medicines. For example, there was no information about how to manage a person with epilepsy if they had a seizure.

At the start of the inspection there was a registered manager in place, by the time CQC returned 4 days later, there no longer was. This in the context of excessive use of agency staff in the first place.

There was a high use of agency staff in the service. Rotas showed on some shifts at least half the staff were agency staff.

Following our first inspection visit we were informed by the CEO and Nominated individual that all the senior staff, including the management team, were no longer working in the service. This had placed increased pressure on the service and as a result, even higher use of agency staff. The provider put in place interim managers from their other services on a rota basis.

Whilst there remained enough staff on shift during our inspection the provider informed us that they couldn’t guarantee this due to their reliance on staffing agencies.

Due to the concerns raised regarding staffing levels and lack of management in the service, we worked closely with the local authority and provider to monitor this situation and risks to people’s safety.

What a state.

A CEO and nominated individual sleeping on duty, seemingly surprised by what CQC found and just get rid of everyone, thereby putting the service under additional pressure. Seems like a pretty reactive and potentially short sighted approach, unless of course they already had concerns or knew it was bad.

This isn’t the only residential care service that Autism Anglia run. Yet seemingly they aren’t really benefitting from working at scale either. With regards to learning when things go wrong and making improvements to ensure that improvements are made to people’s lives, CQC uncovered an apathetic response:

Incidents were reviewed at provider level however this was not always dynamic and responsive enough. For example, a number of incidents involving one person had happened over the course of a few days. However, no feedback to the interim management team on triggers or learning had been provided. The management team themselves had not reviewed this to identify any patterns or concerns.

Given how inadequate Lambert House’s safety rating is, it’s perhaps not surprising that they were also rated inadequate on effectiveness, and there was an absence of any evidence that the care and support provided achieved good outcomes or promoted a good quality of life for people.

CQC found there were ‘widespread and significant shortfalls in people’s care, support and outcomes’. They found numerous, what they described as ‘significant concerns‘ with the physical environment of the home. This palce sounds grim, some of the lowlights included:

• a broken downstairs window which meant communal areas were cold
• a broken radiator cover with rough edges and rubbish shoved inside it
• a toilet with water covering the floor around it
• communal bathrooms in a poor condition, needing refurbishment
• people’s rooms in a poor state of maintenance, with damaged walls and stained, loose ceiling tiles

We identified significant concerns with the of cleanliness people’s environment. Fans in communal bathrooms and toilets were caked in dust and dirt. Jugs on baths in communal bathrooms were dirty as were bathmats. We noted significant accumulation of dust on and around people’s items in their bedrooms.

Once CQC had raised how revolting the environment was, the provider ‘commissioned a deep clean of the service and put in place a schedule of maintenance work‘. Which no doubt contributed to their rating of responsiveness as requiring improvement and not inadequate, despite how grim the place was in the first place and how non existent the provider’s oversight and audit mechanisms were.

CQC spotted that there was another problem, where people weren’t able to access certain areas of their own homes:

Whilst there were communal spaces such as a large recreation room and sensory room, these were not well utilised. On each of our three visits we found the sensory room was locked and therefore not accessible to people.

The Autism Anglia Adult Services Prospectus has this to say about their residential housing:

Our residential services provide a welcome, homely atmosphere in a calm environment and focus on independence, developing new skills and social opportunities…. Above all, an emphasis is placed on those we support being and feeling like a valued part of the community.

Nothing says valued, welcome or homely like the state of this place. Couldn’t be further from it. CQC considered that the physical environment was ‘a breach of Regulation 15 (premises and equipment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014’.

CQC also found that due regard wasn’t given to the Mental Capacity Act, a breach of Regulation 11 (need for consent) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

They found restrictions in place that limited people’s ability to access their personal electronic devices, their own bedrooms, and water. None of which had followed correct process under the MCA.

Returning to the Autism Anglia Adult Services Prospectus, they claim that staff undertake mandatory training when they start working for them, and also that they offer training on the Mental Capacity Act and Deprivation of Liberty Safeguards.

I’ve said it before and I’ll say it again, training on its own guarantees nothing. If there aren’t supports in place, guidance and leadership, and consideration for how to transfer learning from training into daily practice, then it’s all just a tickbox exercise. The CQC inspection team made a number of related observations.

Nationally recognised assessment and support tools were used to support people with distressed or communicative behaviour. However, we received some concerns during the inspection from social care professionals on how effectively staff implemented this approach.

and

We identified serious concerns with staff practice and the support provided to people using the service. This meant, whilst staff had received training in a range of areas, we could not be confident staff were supported effectively to carry out their role.

We spoke with some agency staff who had not been supported to have sufficient knowledge of people and the systems in the service to provide effective support.

In addition to agency staff not being supported to know people well enough to provide good support, there was a distinct lack of care and attention to people’s care plans and documentation. CQC commented that:

People’s needs were not always fully assessed and did not always have supporting care plans.

We identified some instances where language used to refer to people using the service was out of date and did not reflect best practice.

They also picked up on the fact that staff were ‘unaware of guidance and best practice in relation to supporting people in some areas such as bowel management‘. Which is dangerous, and careless and particularly poor given how many people with learning disabilities are at risk of constipation, and the life threatening side effects of it.

The more I read of this report, the more it feels like peaking in the windows of a long stay institution, the like of which are meant to be long since closed.

This is what CQC said about mealtimes at Lambert House:

We observed the mealtime experience and noted this was not a pleasant experience for people. An assigned seating plan for people was displayed in the dining room. This raised concerns about an institutional approach to the support provided. We noted there was little interaction between people and staff, and the room was notably silent.

The same seat every meal, every day, eating in silence. I can’t imagine eating in silence, unless it was a punishment.

Next up, oral hygiene. I’ve spoken about this so often, we all know how painful toothache is (and if you don’t, thank your lucky stars), so imagine if the people paid to provide you with support, neglect to provide support to ensure you have healthy teeth.

Last year I reported from Rachel Johnston’s inquest. Rachel died after an operation to remove all her teeth. She was just 49 when she died in November 2017. At the time the media coverage, and the commentary across social media, seemed to imply that something had gone wrong, or somehow the dentist was at fault. The inquest found that not to be the case. The coroner found that Rachel died as a result of complications of necessary surgery, to which neglect contributed. The neglect was in the care provided once Rachel returned home.

What wasn’t explored in any detail at Rachel’s inquest, was how her teeth had been allowed to deteriorate to such an extent that full extraction was the only viable option remaining. I imagine what CQC found at Lambert House clearly shows how this can happen.

Staff did not ensure good oral hygiene. We observed toothbrushes in people’s rooms which were in poor
condition. Oral health charts were pinned up in the bathroom for staff to record what areas of teeth people had been supported to clean. However, we noted these had significant gaps.

We observed one person grinding their teeth loudly however this was not covered in the person’s care plan or risk assessment. We did not find any consideration of what dental input and advice the person had received had in relation to this.

CQC also found that whilst people at Lambert House had hospital passports, they weren’t kept up to date, therefore it was not clear that correct information would have been provided to hospital staff in the event of a hospital admission.

So many of these well intentioned initiatives actually end up creating additional risk if they’re not implemented effectively, and kept current.

CQC’s assessment of how caring provision at Lambert House was had deteriorated from good to inadequate:

This meant people were not treated with compassion and there were breaches of dignity; staff
caring attitudes had significant shortfalls.

Observations of staff support raised concerns of dehumanising practices within the service. For example, we observed a member of staff sitting in the doorway facing into a person’s bedroom so that the door was unable to close. We observed the person lying on an uncovered mattress. The person was naked from the waist down and was completely exposed to anyone walking past their room.

It always astounds me how ambivalent staff can be, in full sight of CQC. You know the culture is completely out of control when someone is treated this way, in front of a CQC inspector.

Seems like there was a complete absence of dignity on offer for people living at Lambert House too:

During our inspection visits we identified multiple occasions where staff did not act to ensure people’s dignity. At two separate visits we found people using the toilet were not supported by staff to protect their dignity. On one of these occasions one person was left using the toilet for an hour with no staff intervention.

An hour. It’s not surprising that toilets were smeared in faeces really is it. What else were people left to do?

Whilst we noted some individual staff interaction with people was kind and caring, we did not find this to be consistent throughout the inspection.

Most of the people using the service were supported on a one-to-one basis by staff. We observed there was limited engagement from staff with the people they were supporting. On one visit we noted an agency member of staff providing support to one person whilst wearing ear pods and using their mobile phone on several occasions.

Again. Such total apathy, in front of inspectors. Not to mention the disgusting environment already described above. This was another breach, this time of Regulation 10 (dignity and respect) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

All of those living at Lambert House were autistic, and relied on non-verbal means of communication. Despite this, CQC didn’t observe any communication tools being used. They said:

For one person we noted their care plan referenced the use of a communication book. We asked the registered manager to see this and they told us the person didn’t have one.

During interaction with one person using the service staff providing them with support did not support the person to engage with us. As a result, the person was not supported to effectively communicate.

We requested evidence on key worker sessions for people living in the service however this was not provided. This meant we could not be confident systems to support people to express their views were in place.

The CQC inspection team stated that the support they observed ‘was not person-centred but basic and institutionalised’. They highlighted that some agency staff did not have good knowledge of the people they were supporting, or how to support them.

The provider told us they recognised this as a valid concern as a result of the exceptional staffing challenges the provider was facing.

This from the same provider who sacked all of the senior staff and the entire management team of the service midway through the inspection. How did they think that would impact on their staffing, or the care provided to people? How could they not have noticed the problems before the CQC came for a visit?

People’s care plans had not always been reviewed and updated where their needs had changed. It was not always clear why people’s care plans were not being followed.

For example, one person had a care plan in place detailing the use of sensory items. However, the registered manager told us these items were not in use. There was no review or evidence in the care plan to show why this was the case.

No sensory items in use. The sensory room locked. This must be a nightmare for the residents of Lambert House, especially those with sensory loss. Living life in a vacuum, in fact is it living or just existing?

CQC considered these failings to be another breach, this time of Regulation 9 (person-centred care) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

CQC found that there were ‘widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care’.

There was no effective quality monitoring processes in place at the home, and an awful culture, or as CQC put it:

There were serious concerns with the culture and practice in the service which the provider had failed to identify and address. This placed people at risk of harm.

The local authority had carried out their own assessment of the service, shared with the provider, in April 2022 which contained some concerns with staff practice. It had noted that a member of staff was seen sitting outside a person’s room looking at social media on their phone.

At our inspection we noted similar concerns with staff not engaging with the people they supported and a staff member using their mobile phone whilst providing 1-1 support. This meant we could not be confident effective action had been taken to address staff culture at the service.

Almost six months after it was first pointed out, not that it should need pointing out at all, people were still being treated like zoo specimens. Expected to stay in their rooms, while staff sat outside on a chair scrolling on their phones looking at social media. This shouldn’t need saying, but this is not a life.

During the inspection we noted one person’s hair had been closely shaved, the person’s appearance had been significantly altered. We asked the interim management team why this had been done and why. They told us they did not know. We asked them to investigate further and provide us with an explanation. We did not receive one. This raised serious concerns about the oversight and supervision of staff conduct.

Not sure what more would need to be done to make this place an institution. Shave people’s heads. Keep them contained in their rooms. Remove access to their devices, while staff play on their phones. Turn off the water. Leave people sat on toilets for an hour. Insist people sit in the same space at dinner, and eat in silence.

In fact what am I saying, this place is an institution.

The provider was made aware of the significant and serious risks at the service immediately after our initial visit. They took immediate action to address risks identified, however we found the actions taken ineffective. This was because we carried out several visits to monitor risks and improvements and found significant risks remained at each visit.

This is so soul destroying. A large regional charity. Commissioned to provide support to a large number of people. All the promises and claims on their website. With sleeping oversight, who step in to take swift action after CQC point out what’s wrong… but don’t actually fix anything.

People’s records had not been updated when their support had changed which meant the information held was inaccurate. Ensuring records are complete, accurate and contemporaneous is a regulatory requirement.

Governance systems were not effective in ensuring compliance with regulations. The quality and safety of the service had not been effectively assessed and monitored, systems to ensure risks had been assessed and mitigated were ineffective, people’s care records were not complete and accurate. This was a breach of Regulation 17 (good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations.
2014.

CQC identified a closed culture during its time at Lambert House and immediately raised a number of concerns with the local authority:

During the inspection we found practices that raised concerns about abuse of people living in the service. People were not treated in a respectful and positive manner. Our concerns were shared immediately with the local authority who commenced a number of safeguarding investigations.

Leadership in the service had been weak and had failed to ensure staff understood their responsibilities and roles. Staff did not understand what was expected of them and how to promote people’s dignity.

During our inspection we received information from health and social care professionals that indicated the provider was not being open and honest with people and their families regarding the significant concerns found at the inspection. This included allegations of abuse that had occurred at the service.

The state of this place. The state of the CQC formulaic report that then ends by reporting on working in partnership with others by stating this:

The provider worked closely with CQC and the local authority to respond to the concerns identified. They engaged in regular monitoring meetings and were keen to work with other stakeholders in order to ensure the safety of people living in the service.

So, the leadership was weak. Ongoing safeguarding investigations. Concerns about Duty of Candour and the provider not being honest and open with families…. but they worked with CQC and the LA to respond…. while deceiving families.

CQC served a notice of decision imposing conditions on the provider’s registration. You can read the conditions imposed on their website here.