A couple days ago I wrote a post about Achieve Together collecting awards for supposed excellence from Laing Buisson, at the very same time as the health and social care regulator, CQC, were finding their services to be failing people, not just a little, but a lot.
Today I’m back with another new report from CQC, published yesterday, that finds another one of their services, Sheringham House in Gravesend, Kent to be inadequate.
How do inspector’s describe the service?
Sheringham House is a residential care home providing a regulated activity of personal care for up to 10 people. The service provides support to people with a learning disability and autistic people. At the time of our inspection there were 9 people using the service. The service was a large home and people’s rooms were on the ground floor and first floor.
There is surprisingly little publicly available to explain why the Laing Buisson Awards panel considered that Achieve Together were fitting to win an award. This was all I could find for the specialist care category:
So a highlight of the Achieve Together application “included their communication with innovation on the new platform” because nothing says specialist care like a new ‘platform’ and ‘innovative communication’.
Let’s have a look at what CQC found at Sheringham House. Whether there was specialist, innovative care and communication.
People were not always supported by staff to pursue their interests or supported to achieve their aspirations and goals. We looked at one care plan which contained no detail about what the person wanted to achieve in their life. Staff did not support people to take part in activities and pursue their interests in their local area and to interact online with people who had shared interests. People did not take part in meaningful activities; this was in part due to the staffing numbers. One relative told us, “They [staff] always say they need more drivers to take people out, they do so little for [person].” Staff members told us people were not going out enough.
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 service did not have enough appropriately skilled staff to meet people’s needs and keep them safe. People were not always getting their one-to-one support hours and we observed on more than one occasion people being left alone without their one-to-one staff member. People who had individual ways of communicating, using body language, sounds and pictures cards were not always supported by staff to do so. We did not see staff using picture cards to interact with people whose care plan outlined this was a method they liked to use. People’s care and support plans did not reflect their range of needs and this did not promote their wellbeing and enjoyment of life. One relative told us, “[person] hadn’t been out for nearly a month.”
People did not consistently receive good quality care and support. We observed staff supporting a person in an unsafe way, which could cause injury. Our observations were shared with a senior manager. Staff had received manual handling training however some staff were using poor practice without questioning it or raising it as an issue. Staff turnover was high, which did not support people to receive consistent care from staff who knew them well. One relative told us, “[person] needs someone to take [person] out, they always say there is no drivers.”
Award winning specialist care eh.
Communication not supported. No fancy platforms but simple picture cards, that enable someone who doesn’t communicate with words to still have influence over their lives, but no, not fancy enough for Achieve Together, so people were silenced.
This service has been in Special Measures since March 2022, when it was last inspected and viewed to be inadequate. That inspection actually took place in January, so as I’m typing this those living in this place have been receiving inadequate care for close to a year. Achieve Together acquired the service in October 2020 and at the time the service was rated good, following an inspection in February 2020.
Since then, people have endured lockdown, and now this substandard excuse for a life. How horrendous it must be for them. What happened after the last inspection? The usual:
The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider remained in breach of regulations.
Let’s look a bit closer as to what inspectors found on this occasion. There was no registered manager in post. I’ve covered the dangers of this in multiple previous posts so I wont repeat, save to say that they, together with the provider, are the ones legally accountable for the service.
First up, safety, had things improved from their inadequate rating earlier in the year. Spoiler alert: no.
At the last inspection the provider failed to always manage risks associated with people’s care in a safe way. We identified concerns relating to managing health needs, the physical environment and staff COVID-19 testing. This was a breach of regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Not enough improvement had been made at this inspection and the provider was still in breach of regulation 12
The provider had failed to ensure people’s individual health risks and risks from the environment had been fully assessed and mitigated. The service did not consistently keep people safe through formal and informal sharing of risks and management strategies.
But what does that actually mean? There are only 9 people living in the home, one less than earlier in the year. How difficult can it be as a provider of specialist care with innovative communication?
People who lived with epilepsy did not always have a detailed plan in place for staff to follow. We spoke to a staff member regarding a person who wore a protective helmet to reduce the risks from falling during a seizure. During inspection we noticed the person was not wearing their helmet. The staff member told us they were informed by the manager that the person didn’t need to wear it. However, when another member of staff came in, we heard them being informed by the deputy manager that the person should be wearing their helmet. There was no guidance or reference to a protective helmet in the person’s care and support plan. Not all staff knew when the person needed to wear it and they were at risk of injury if they had a seizure and fell and hit their head.
These are basics. Failing on the basics, with potentially life threatening consequences.
People who had dysphagia were at an increased risk of choking as there was not enough guidance in place for staff. Dysphagia is a medical term used for people who have swallowing difficulties. Some people’s care plans identified what level (consistency) of food they needed according to their SALT (Speech and language therapy) assessment, however there was no guidance on what types of food were suitable for people’s individual levels. IDDSI guidance details foods such as sausages and peas are unsuitable to be pureed. During the inspection and other occasions, as identified in the daily care notes, these types of food were pureed for people with dysphagia, increasing their risk of choking.
Last year I reported from the inquest of Peter Seaby, who died from aspiration pneumonia. We heard in court that staff failed to follow the SALT recommendations for his diet and supervision of him when eating.
We know that 1 in 5 deaths of learning disabled people are as a direct result of aspiration pneumonia, and you have an increased risk of that if you are reliant on others for care, and for helping you with eating and drinking. Or if you have difficulty with eating, dysphagia, or difficulty with your swallow.
Yet, here at Achieve Together, there is a carelessness about epilepsy, and dysphagia, both known risk factors for premature and preventable deaths in learning disabled people.
It seems that very little care or attention was given to people’s nutrition and meals:
People who were at risk of becoming underweight were not supported by staff to follow their SALT assessment guidance. Some people’s SALT guidelines detailed they needed fortified food to aid with weight gain. Fortified food includes full fat creams, milks and yoghurts that can be added to food to increase calorific value. There was no additional food available in the cupboard or fridge to ensure food could be fortified. When we asked the staff member who was preparing the lunch on the day of inspection, they were unsure what fortified food meant and confirmed this had not been happening.
So many basics were missed here. Innovative specialist care it most certainly is not:
Staff had failed to ensure they consistently supported people in line with safe moving and handling guidelines. We observed two staff members supporting someone in an unsafe move called a ‘drag lift’. A drag lift is a widely recognised unsafe manual handling manoeuvre where staff pull someone up from under their arms. This move can cause pain and injury to the person and staff members.
Add to that CQC found that the environment itself was not always safe:
The environment was not always safe for people. The registered manager had not ensured areas of the garden were tidy and free from risks to people. There were a number of bins in the garden that had an open top containing used gloves and masks, which posed risk of spreading infection. There were people in the home who displayed PICA behaviours and were at risk of going through bins and attempting to eat items. PICA is an eating disorder where the person would eat inedible items.
There was a large area of stinging nettles in the garden and a broken flowerpot in the sand pit that people used. People who lived there had free access to garden and we observed people accessing the garden. Following the inspection, the provider informed us they had addressed immediate the safety issues and were committed to carrying out improvement works in the garden to ensure people’s safety.
Here’s the thing though. Presumably they made the same reassurances after the last inspection. But if you look at that report, it includes an identical issue:
We noted the bin in the front garden that stored people’s soiled continence aids was unlocked which was a particular risk for the people at the service that had Pica disorder (Pica is the eating or craving of things that are not food).
At the last inspection CQC noted the unsafe staffing levels and that Achieve Together were in breach of Regulation 18. They’d not made sufficient improvement and they remained in breach:
The provider failed to deploy sufficient numbers of suitably qualified, competent, skilled and experienced staff. This was a continued breach of regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Interestingly CQC have noted the workforce pressures across social care, whilst highlighting Achieve Together’s ongoing failures:
Health and Social Care services are experiences significant workforce pressures widely across the sector, however the provider had not taken appropriate action to mitigate the impact of this on service users following the findings at the last inspection.
The service did not have enough staff. People were not receiving consistent one-to-one support to take part in activities and go out when they wanted. We observed on more than one occasion, one person not being supported by their 1-1 member of staff. The home manager told us that six people needed 1-1 support but there was not always enough staff to support their 1-1 hours. One staff member told us, “If we had more staff they (people) could go out more. Also having to do the cooking and cleaning impacts on how much time we have to spend with people.”
The impact of the unsafe staffing levels is that people were kept at home, unsafely, and denied the opportunity to go out and lead anything approximating a life.
The numbers and skills of staff did not match the needs of people using the service. One person needed the support of two staff members when leaving the home. The rota did not allow for this 2-1 staffing and therefore the person did not leave the home as often as they wanted. The daily notes for this person detailed, on more than one occasion, that they had requested to go out but had been unable to due to staff shortages.
I don’t think its too much to ask that award winning specialist care should keep people in their care safe, but this service has a long list of safety failings. Including in relating to safeguarding people from abuse and neglect, and learning from incidents.
At the last inspection the provider failed to ensure accidents and incidents were monitored, recorded and reported. This was a breach of regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Not enough improvement had been made at this inspection and the provider was still in breach of regulation 12
The home manager did not have a robust system in place to have oversight of incidents or accidents. There was no analysis in place to pick up any trends or patterns. The service was in the process of moving from paper-based incident reporting to computer based but this was yet to be embedded.
Wonder whether this is the apparent ‘platform’ that will allow for innovative communication, my hunch, albeit as an outsider, a cynical one who’s reported on social care failings for too long, is that garbage in = garbage out. If staff can’t identify failings to record in the first place, doesn’t matter how fancy pants your platform is, it isn’t going to help. Not to mention your failure to recruit and retain enough staff to actually input into the ‘platform’. What did CQC find on this inspection:
Staff were not always able to determine what was an incident, accident or behaviour.
There had been no incidents or accidents recorded online or in the folder since the middle of July 2022. The home manager told us some things might be recorded on behaviour forms. There were incidents of physical aggression on the behaviour forms that had not been reported using the providers incident reporting policy.
The home manager told us staff needed further learning to identify what qualifies as an incident or accident. When incidents and accidents are not recorded in line with the provider system, the home manager is unable to have a clear analysis and oversight.
The provider failed to ensure accidents and incidents were monitored. This was a continued breach of regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Not surprisingly given these failings, there were also failings in relation to safeguarding:
Safeguarding systems and processes were not robust to ensure people were always protected from the risk of abuse. Safeguarding records did not always highlight what action had been taken when concerns were raised. For example, there was an incident where a person had self-harmed and the home manager was unable to confirm if this had been reported to the safeguarding team. Other incident forms did not always detail whether safeguarding or CQC had been informed.
One person’s monthly key worker review detailed they had three incidents reported to safeguarding during that month. It did not outline what these incidents were and when we asked the home manager to see the incident reports there was only one incident recorded.
This is too long already so I’ll not go into each domain in detail. In addition to the 3 repeated breaches in relation to safety, there were 11 breaches of regulations, including 7 repeated breaches in other domains. These were in relation to:
Regulation 9 (the provider failed to ensure care was designed to meet people’s needs and preferences)
People’s care and support plans did not contain information about goals and aspirations… One relative told us, “Staff do not seem to have the initiative to do stuff with people.”
Regulation 12 (risks associated with people’s health needs were not always being met). CQC found delays in taking people to healthcare appointments and no follow up actions taken after an appointment.
Regulation 18 (the provider had failed to ensure that staff received appropriate training and supervision)
At the last inspection supervisions were not carried out regularly and training was not always effective and up to date. At this inspection the same concerns were identified… a number of staff that had not a supervision meeting with their manager. The communication book and staff supervision notes highlighted that staff attendance at training was low. One staff member told us, “There was a big drive for us to do the online training, but we have to do it in our own time, on our day off.”
Regulation 9 (the provider failed to consistently ensure people’s nutritional needs were met)
People did not consistently receive support to eat and drink enough to maintain a balanced diet. Staff told us the food shop did not contain enough nutritious food for people. For example, one staff member told us, “They need to have improvements like more veggies, we should promote more healthy food. Crisps and chips are given a lot.”
Regulation 11 (the service failed to consistently gain consent from people in relation to their care). Inspectors noted that on the morning of one of their visits someone was being moved out of their bedroom, due to the changing needs of someone else in the home.
The decision had been made on that morning without any discussion with the person or their relatives.
It’s like people are just units to be moved around at the businesses pleasing. It’s almost like these aren’t people’s homes, but they’re just warehouses or storage units.
Regulation 10 (the service failed to consistently treat people with dignity and respect).
Staff did not consistently respect peoples likes and dislikes regarding food and meals times. One person’s care plan outlined if they disliked something they would ‘close their mouth and use their hand to push the spoon away. This was an indicator they did not want any more. We observed a staff member offering this person a spoonful of food. The person kept their mouth shut and the staff member persisted seven to eight times before the person pushed the staff members arm away.
Innovative communication on technology platforms… when the absolute basics of communication, listening and treating people with respect are missed. Another example which CQC considered to be a lack of respect, borderline for abuse if you ask me, and if this is in front of CQC inspectors, what happens behind closed doors?
We observed care that was not always respectful. For example, one person was laying on the floor and a staff member told us this was usual behaviour for the person. The staff member said, “(Person) doesn’t like this.” and then proceeded to tickle the person, which made them get up off the floor.
We intervened and advised the staff member that if the person didn’t like it, then staff should not be doing it. This incident was highlighted to a member of the management team who addressed the concerns and had discussions with the staff involved.
Regulation 9 (care and treatment did not meet people’s individual needs)
At the last inspection people were not supported to take part in meaningful activities and people’s care plans lacked detail around what things they liked to do. At this inspection we identified the same concerns.
People were not being supported to engage in meaningful activities. We looked at daily records and activities log chart for one person. During 23 days in August 2022 the person had only left the house twice.
The daily notes detailed the person was ‘agitated due to not going out’ and ‘[person] calmed down when told they would be going for an outing with relative in 3 weeks time’. When we spoke to staff about why this person wasn’t going out they told us, “[person] is active and would benefit from going out more, if we had more staff, we could do more.”
Twice. Imagine leaving your house twice only in over 3 weeks.
There was a reason that people were allowed out for a short walk even in the height of the covid lockdown, because people’s mental health was known to suffer if they didn’t have that chance. Only some humans are considered fully human though aren’t they.
People were not being supported to pursue their interests or hobbies. For example, one person’s support plan detailed they would like to attend the local church, however this was not happening. Another person’s support plan detailed they liked country walks and would like to visit different parks, however this was not happening.
During the two days of inspection, people were not supported to go out or supported to take part in meaningful and person-centred activities. One staff member said, “We struggle to keep people’s attention.”
Relatives told us they were not updated about activities their loved one participated in. For example, one relative told us, “Communication could be better with what [person] has been up to.” Another relative told us, “There is always an atmosphere in the home and its boring, staff sit around watching tv.”
Always the TV on, blaring, while people rot in these homes. Non-lives, as offered by award winning care providers. Experts in innovative communication, or not.
Regulation 9 (The service failed to deliver person centred care)
One person had a communication passport in place which identified they liked to use Makaton, picture cards and objects of reference to express their choices and wishes. However, staff had not received Makaton training.
Two people’s care plans detailed staff should use objects of reference to help them understand. However, during inspection we did not see staff using objects of reference to support people to communicate.
Regulation 17 (the provider failed to have robust oversight of the service and failed to make the necessary improvements to the culture of the service)
At the last inspection the provider had not identified the impact of people not being able to take part in meaningful activities. At this inspection they had failed to make improvements.
The provider had failed to ensure there was a robust system in place to have oversight of people’s daily activities.
The provider had failed to instil a culture of care in which staff promoted people’s individuality and enabled them to develop and flourish.
The provider failed to ensure management were always available to support staff. Staff members told us, “We don’t have enough support, they spend too much time in the office.”
Staff members told us they felt not enough focus was being put on caring and supporting people but instead focusing on other issues, for example one staff member told us, “A lick of paint and new sofas won’t do it, a number of staff have left since Christmas.”
One relative told us, “There is endless excuses as to why [relative] is not going out”.
I feel like this report reads like a microcosm of the reality of the social care crisis.
Not what CEOs, leaders and spokespeople of large providers would have you believe but the reality on the ground. Unsupported staff who see the window dressing of a lick of paint, and senior staff sitting around in offices, and not enough focus on the people they’re supposedly there to support. Utterly demoralising environment for staff and the people in their care. Continued breach after continued breach, here’s another.
Regulation 17 (the provider had failed to undertake robust quality checks)
At the last inspection the provider failed to undertake robust quality checks and ensure accidents and incidents were monitored. At this inspection similar concerns were identified. Governance processes were not effective and did not hold staff to account, keep people safe, protect people’s rights and provide good quality care and support. The provider had failed to improve the service since the inadequate rating from the previous inspection.
The provider failed to ensure that notifiable incidents had been reported to the Care Quality Commission under their registration. We identified four alleged incidents of abuse between people in the service had not been reported to CQC.
Regulation 17 (the provider had failed to adequately evaluate and improve care)
The provider had not worked well with the funding authorities when identifying people’s assessed 1-1 needs. The provider was not able to tell us exactly how many 1-1 hours of support people were getting every day. Some people needed 2-1 support when leaving the service but due to the low number of staff this was not often possible. The provider was unable to demonstrate how 1-1 funding from commissioners was being used.
Staff told us they felt there was a divide between the home management team and staff on the floor. One staff member told us, “It feels very them and us.” Another staff member told us, “I don’t feel like [managers] support us, it’s the general feeling on the floor”.
I’m pretty sure in any other business if you took people’s money for a service and failed to deliver it, routinely, that would be considered fraud.
In total there were 14 breaches, 10 of which were repeated from the last inspection, which took place almost a year ago in January. Learning disabled and autistic people having their human rights breached, repeatedly, while the provider of their care is busy on a propaganda awards bandwagon. I find it sickening.
At the same time as this report, two more of their services received reports indicating they Required Improvement, which meant they were also providing sub standard care.
Which means in the last month Achieve Together have had 3 services rated inadequate, and 7 require improvement: Upper Selsdon Road, Holly Tree Cottage, Apple Tree House, Barron Winnicott Home, Pendean Court, Merrington Grange, 42 Twyford Gardens.
In the same time period only 5 were rated good and none outstanding. Which means you’re twice as likely to receive care that’s not meeting bare minimum standards.