What do you get if you cross an electrician and a psychiatric nurse practitioner? Inadequate care for vulnerable people. At least that’s the case here.
Whenever I see a CQC report with this many domains marked inadequate I have to dig a little deeper.
I usually start on the CQC’s own website. Which on this occasion tells me that this is a newly registered service (31 May 2022) and that Primrose Sarudzai Betera is responsible for the service. The registration information tells me that this service apparently replaced an existing service, which provided the same support, has the same name and was registered on 24 June 2020 and archived on 1 June 2022. This service wasn’t inspected in the time it was registered, but the Nominated Individual was the same person, Primrose Betera.
Next I have a look at that person and find that Ms Betera claims on her LinkedIn profile to be a Psychiatric Nurse Practitioner. A quick check of the NMC register shows that she’s a Registered Mental Health Nurse since 2002, with her registration up for renewal in February 2023. She has no qualifications listed and no restrictions on her practice.
After that I popped over to Companies House to dig a little deeper still. There I find that the company is still registered at the old address, that was apparently archived earlier this year. There I also discover that there are two current directors of the company, Ms Betera, who has been a director since 2017 and here describes herself as a Nurse and Best Interests Assessor, and Adewale Ishola who was appointed director in February 2022 and describes his occupation as an electrician.
What did CQC find when they visited. Remember this is their first visit since the previous service was registered in June 2020, it was never inspected before it morphed into this version of the company.
Re-Enabled Support provides personal care to people in their own homes within supported living and domiciliary care settings. Not everyone who used the service received personal care. 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 the inspection there were 9 people receiving personal care, some of whom may have a learning disability, autism, mental health needs, sensory impairments or physical disability.
So two types of service provision, some support for people in their own homes via domiciliary care service adn some in Supported Living. Were they any good?
The provider was not able to demonstrate how they were meeting the underpinning principles of Right support, Right care, Right culture.
Staff were not all safely recruited and did not all have a DBS in place. Risk assessments did not hold sufficient information for staff to meet people’s assessed care and health needs. The provider had not fully protected people from the risk of abuse and improper treatment. Incidents and accidents involving people were not consistently reported, recorded and investigated.
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.
Assessments of people’s individual needs had not been consistently recorded and did not consider best outcomes for people. Care plans were not person centred and did not hold sufficient information to guide staff when supporting people. The provider had not fully explored how to present information in an accessible way to meet individual needs. The provider failed to ensure there were enough trained and competent staff to meet people’s needs and keep them safe.
Governance systems were ineffective. The provider had failed to implement systems to assess, monitor and improve the service. Staff did not receive support through training, supervision and meetings to ensure they have the knowledge and skills to meet people’s needs. We found the language used in some people’s care plans to be disrespectful and undignified. Lessons were not learned from accidents and incidents to drive improvement.
CQC inspectors identified a number of legal breaches:
We have identified breaches in relation to person centred care, need for consent, safe care, medicines management, safeguarding, staffing and governance at this inspection.
The first of these related to safeguarding people from abuse, regulation 13 (Safeguarding Service Users from Abuse and Improper Treatment) of the Health and Social Care Act 2008 (regulated activities) Regulations 2014, something I’d expect a registered nurse to be familiar with.
Systems to protect people from the risk of abuse or neglect were not in place. The provider had a safeguarding policy and procedure, however, were not following the guidance within this. For example, the policy states all staff will receive safeguarding training and be DBS checked. We found gaps in these areas.
The service was under organisational safeguarding. Organisational safeguarding is a process employed by the local authority to monitor the service where there are multiple concerns. Safeguarding alerts had been made by the service to the local authority, although these records lacked detail and did not demonstrate what action had been taken to mitigate immediate risk.
Staff had not all received safeguarding training to ensure they knew how to identify and report abuse
I dread to imagine how such a new service ends up under organisational safeguarding already. Although given their lackadaisical approach to risk I imagine they’ll need such close scrutiny for some time to come:
People’s risk assessments were either unclear or were not in place to ensure known risks were mitigated. We identified significant risks from people’s care records that risk management strategies were either not clear or did not exist. For example, one person was supported with manual handling; however, they did not have appropriate equipment to support them and not all staff had received appropriate training or had their competency assessed.
Risk assessments and support practices in some instances included unjustified restrictions. For example, within one shared living accommodation fridges were locked without consideration of the least restrictive measure. There were no risk assessments or care plans which detailed the reasoning for this and if it was in each person’s best interest.
The provider did not have a process in place to analyse, identify trends or learn lessons to improve on the service provided. The provider was not following their serious incidents reporting policy. For example, the reporting and
investigating of restrictive practices was not being followed.
The locked fridges I find particularly surprising given Ms Betera is identifying herself as a Best Interests Assessor. Here’s a handy summary from SCIE on what BIAs do:
Best interests assessors are the lynchpin on which the entire edifice of DoLS rests, and they have a range of duties that fall to them within the operation of the Safeguards.
Best interests assessors are often the main assessors though a mental health assessor may also assess capacity. They are responsible for ascertaining that the person is 18 or older (the age assessment, now generally incorporated as part of the best interests assessment). They are solely responsible for assessing whether there are any lawful decision-makers who object to what is proposed (the ‘no refusals’ assessment).
Most significantly, they must carry out two vital tasks: they are responsible for deciding whether a restrictive situation is authorised by Sections 5 and 6 of the MCA, or whether it amounts to a deprivation of the person’s liberty. If they conclude, given all evidence and scrutiny of the concrete situation of the person, and in the light of current case law, that the person is deprived of their liberty, they must assess holistically whether the restrictions are in the person’s best interests, and proportionate to the risk and seriousness of harm to that person without the proposed restrictions. They must keep abreast of developments in case law to carry out these tasks correctly.
You’d think her service would be all over the Mental Capacity Act and least restrictive practices. Let’s have a look more at the report and see what else inspectors found, relating to quality of care and whether it met people’s needs:
People and their relatives were not fully involved in the assessment of their needs. The provider had failed to complete a comprehensive assessment of each person’s physical and mental health needs. This meant people were at risk of receiving care that was inappropriate to their needs.
Care and support plans did not reflect people’s needs, likes, dislikes, goals or aspirations. Support plans did not always focus on people’s quality of life outcomes or meet best practice guidance.
People were not always supported to make choices about their care and they, or their representative were not always involved in decision-making or reviews. This placed people at risk of harm. This was a breach of regulation 9 (Person Centred Care) of the Health and Social Care Act 2008 (Regulated Activities) Regulations
In relation to the MCA
We checked whether the service was working within the principles of the MCA, whether appropriate legal authorisations were in place when needed to deprive a person of their liberty, and whether any conditions relating to those authorisations were being met.
The provider was not working in line with the principles of the MCA. They were unable to evidence that people’s rights under the MCA were being protected. Assessment and care planning processes did not always consider people’s capacity to consent to care and treatment.
Three people were being supported on a one-to-one or 2-to-1 basis. We found no evidence of how the decision to supervise people in this way had been made or any considerations of this being in their best interests.
Where people could not make specific decisions for themselves, a best interest decision was not in place. Consultation with people, their relatives or healthcare professionals as required under the principles of the MCA was not in place.
Staff knew about people’s capacity to make decisions through verbal or non-verbal means; however, this was not always documented. This meant there was a risk that decisions made for people might be unlawful or not in their best interests.
The provider had not consistently acted in accordance with the requirements of the Mental Capacity Act 2005. This was a breach of Regulation 11 (Need for Consent) of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
How can this be so? How can any registered nurse, never mind a registered mental health nurse who also apparently holds specialist training in the Mental Capacity Act, oversee such poor practice?
Inspectors commented that the language used in some people’s care plans was “disrespectful and undignified” and “uncaring”.
For example, “[Name] is very childlike in their manner”, “When out in the community they make unnecessary and at times offensive remarks” and “Needs 2:1 support due to their behaviour.”
They also noted that:
People’s life histories, preferences, likes and dislikes were not included in their care plans to help staff develop a relationship with them and to provide care and support that met their needs.
Care planning seems atrocious:
People’s independence was not prompted within the care plan records. They did not describe what people could do for themselves and what support they needed with specific tasks. For example, one person’s care plan stated “[Name] requires support with personal care.” No additional information was available to support this.
Care plans did not hold sufficient information to ensure staff could offer the right level of support. For example, one care plan stated “[Name] requires support at night when unwell.” This does not give clear guidance to staff.
What sort of support is actually being provided in this environment, what could be provided.
People’s care and support plans did not always focus on positive outcomes to improve their quality of life. There was very little evidence that staff supported people to identify aspirations for their future.
This is not a life.
Additionally there were concerns about communication and a failure to ensure people’s communication needs were met.
There were numerous failings documented in the assessment of whether the service was well-led. These are just the opening observations.
Governance processes were ineffective and failed to keep people safe, protect people’s rights and provide good quality care and support. The provider had not identified the concerns we found at this inspection, including the lack of robust risk assessments in care planning processes, lack of person centred care plans, unsafe recruitment procedures and lack of staff training and competency assessments.
The provider had not established robust systems and processes to enable staff to record a report accidents and incidents, and to ensure these were thoroughly investigated to minimise the risk of future reoccurrence and drive improvement in the service. This meant people were at risk of avoidable harm.
Records including mental capacity assessments, medicine’s records and staff records were not always accurate, complete and up to date. People’s records did not always contain important information such as their health conditions, list of medicines, next of kin, GP and any known allergies. The lack of adequate information placed people at risk of receiving unsafe care and treatment.
As with any recent CQC report enforcement action isn’t listed immediately. However the standard process, as outlined at the beginning of the report, for services in special measures, is that they produce an action plan that they submit to CQC detailing what actions they’ll take to improve things.
There’s an obvious problem with this approach already identified in the report, the classic performative scrutiny. Do the bare minimum to appear to be addressing an issue, write the plan, and do nothing.
The provider had started an action plan to drive improvements within the service in response to concerns raised by the local authority and a consultant that was working with them. Actions identified had not been addressed.
Will keep my eyes peeled to see what happens next.