Still playing catch up, have moved to a sprinkling of reports of inadequate care for autistic people and people with a learning disability, published in October 2023.

We’ll start with our friends Achieve Together, I’ve written about their inadequate care before here, here and here. Remember they’re the ones that claim they “endeavour to be a continuing leader in best practice across the country and ensure that the people we support have every opportunity to fulfill their potential”. Except for those people in Shrewsbury I guess.

Highbury House can support up to 11 people, but at the time inspectors visited there were 10 people living there. The first red flag is that it’s made up of 3 neighbouring properties… so I guess really its an institution contained within three buildings.

At an inspection in June 2022 Highbury House was rated as requiring improvement and breaches of regulations were found. This inspection, in July 2023 was a follow up to check that they were no longer in breach, except they were, and in fact things were worse.

At our last inspection, we found concerns related to staffing and management oversight of the service. These concerns resulted in regulatory breaches. In response to our last inspection the provider sent us an action plan telling us how they were going to make the required improvements.

At this inspection, there continued to be a lack of effective oversight to ensure standards and regulations were maintained. Some areas previously identified as a concern, remained. We also identified additional breaches of the regulations. Examples of audits were either not completed or they were ineffective when completed, in identifying where improvement was needed. Several improvement actions we found during our visit had not been identified through any provider checks at the service. Issues with staffing identified at the last inspection remained.

There were a number of failings identified including people not being supported to have maximum choice and control of their lives and staff not supporting them in the least restrictive way possible and in their best interests.

The evidence to confirm people’s restrictions had been imposed in their best interests could not be located and a number of Deprivation of Liberty Safeguards (DoLS) authorisations had been allowed to expire. Staff involved people in making day to day decisions. However, people’s ability to decide was often limited, due to the staff and resources available. People were supported at mealtimes and guidance was in place around healthy eating. However unfamiliar staff and reduced food supplies impacted people’s choices.

When you think about the amount of money being paid to providers to provide care, and they are so focused on profit they don’t even keep food supplies topped up. This industry is repulsive.

Medicines guidance was not always person centred and people were not always protected from the risk of harm.

The governance systems in place continued to be ineffective. Issues found at the last inspection remained and further issues were identified as requiring attention. The providers systems and processes were not robust, effective or embedded, with a lack of oversight that failed to identify significant gaps in the quality of the service people received.

The provider had not submitted notifications in line with regulations. This issue was identified prior to the inspection and remained unresolved. We understood there had been some management changes which had a negative impact on the service. For example, the significant back log of accident and incidents requiring review. Systems and processes failed to offer assurance the provider knew of cases of potential harm, be that accidental or deliberate. Those systems failed to record if appropriate actions had been taken to keep people and staff safe or whether the action taken was proportionate to the circumstances.

Not only was governance poor, the culture was rotten too, and again inspectors heard from staff trying to do their best for people, when managers and providers were failing them.

The culture in the home was not person centred. Some people had had positive experiences in the past year. They had been on holiday and developed new relationships. However, some people remained limited in what they could do due to the staffing situation and behaviours of others. This was despite 1:1 funding being in place.

I can’t wrap my head around all this 1:1 funding being paid to providers, and commissioners or social workers, or anyone, not noticing it wasn’t being provided. Of course the people stuck in the home, and a relative had noticed and observed the impact of poor staffing, but no-one who was paying for it and notionally overseeing it.

People were also frustrated by the lack of regular staff. We observed 1 person speaking with staff on 2 separate occasions trying to arrange activities for themselves and establish whether they would have regular staff or agency staff on a given day to support them. When we asked people, they confirmed the staffing situation was frustrating and they would like more consistent staff.

The staffing numbers and people’s ability to access the community was a concern for some families. One relative told us, “They used to do loads of community activities but since covid nothing seems to have restarted, it must be so boring at times.”

Maybe this is Achieve Together’s vision for people achieving their potential? Who knows.

Staff were clear with inspectors about their efforts, and the impact of management and the provider being so absent.

Staff engaged positively with the inspection process and the majority of staff told us they felt there was a divide between the staff team and the provider which was impacting on their wellbeing and affecting the outcomes for some people.

One staff member said, “We are all committed which is why we are still here, and we know it will improve but management need to work with us and listen to what we know works and doesn’t work. Sometimes they expect us to do too much and when staffing is low this can affect people’s behaviour which puts us at increased risk. This makes me anxious.”

We shared the concerns with the management team who said they would be increasing their engagement with staff and ensuring adequate support was in place.

Achieve Together made promises, no doubt similar to what they did after the last inspection, but they remain in breach and are now inadequate and in Special Measures. So we’ll wait and see what happens next.

Next up we have a learning disability charity, Avenues, who claim on their website that:

People need to live in the place they call home, with the people and things that matter to them, in communities that look out for one another, doing the things they love.

They also state they have a shared expectation. Guess that’s meaningless too.

It’s our shared expectation that all our services maintain a Good or Outstanding overall rating from the CQC, which is the regulator for social care in the UK.

Following a July 2023 inspection, in October Avenues South East 1-3 Emily Jackson Close in Sevenoaks was rated inadequate.

Another institution in plain sight, there were 18 people living across three bungalows when inspectors visited. This is what they found:

Right Support: 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. For example, one person did not have any documentation regarding a restriction detailed in their care plan. People’s care plans did not always contain information about how staff can support them to achieve their goals and aspirations. The service gave people care in an environment that was not safe or clean. For example, one person had mould on the shower trolley (A shower trolley is a convenient and secure facility allowing the service user to safely shower in a comfortable lying position) and cleaning chemicals were easily accessible and not locked away. People were supported to visit the home before they moved in. Although this took place staff felt people had not been properly consulted. One person also told us they hadn’t been informed a new person had moved in.

Right Care: Not all staff understood how to protect people from poor care and abuse. For example, staff had not recorded or reported potential safeguarding incidents to the local safeguarding team. People’s care an support plans did not consistently reflect their current needs. For example, one person’s support plan had not been updated when their eating and drinking needs changed, their care plan was last updated in 2021. We observed staff to not always being caring. For example, one staff member referred to the effects of a person’s Parkinson’s condition as them doing this for attention. This showed a lack of consideration and empathy for the impact Parkinson’s had on the person.

Right Culture: People did not always lead empowered lives. People did not consistently receive good quality care and support. For example, staff had not always received training in areas needed to support people with all their health needs. There had been inconsistent management at the service and a lack of role models for staff. Relatives told us ‘It’s very hard to speak with staff as they are always busy.’ Whilst we received some negative feedback, relatives also gave some positive feedback about the care provided, for example, ‘Cannot fault the care, he has never been surrounded by so much love and care.’ The provider had processes in place to gather relative’s feedback, however we received mixed reviews as to whether this was effective. One person told us, “They used to do fortnightly calls but realistically I can’t expect that now.” However, other relatives told us they were happy with the process to give feedback.”

Inspectors identified “4 potential safeguarding incidents that had not been recorded effectively for management review or reported to the local safeguarding team”. One relative told CQC that they did not feel the home was safe:

“I feel I must speak up – it is a serious accident waiting to happen. I’d feel awful when it happens and I hadn’t spoken out. It has become unsafe for them all.”

One of the potential safeguarding incidents detailed someone being hit on the head by another person in the service. A failure to pay attention to dynamics in services, and the potential impact of that, costs people their lives. In July 2022 I reported from the inquest of Robert Chaplin who died having been punched by another person living in the same service as him.

In this case inspectors found that incidents were not consistently recorded on the online system, and even when they were, they were not escalated appropriately.

Three of the incidents had not been recorded on their online system. The incidents had been recorded on paper and filed away in care plans.

The Assistant Service Manager was aware of one of the incidents but had not escalated this to senior management or the local safeguarding team.

The other incident had been recorded on their electronic system as a ‘behaviour’. This had not been reviewed by senior management or reported to the local authority safeguarding team.

The state of this. Record it and just file it away. Record it, management know about it and do nothing. Record it as a “behaviour”, I am convinced that the cult of positive behaviour support has so much to answer for. What does it even mean?

One relative told us the dynamics of the people who live in the service has changed as there had been incidents, “The other people are traumatised. They have gone from happy and calm to a nightmare.”

How can providers be oblivious to this? In people’s home?

And yet more evidence that training fixes nothing, if the culture isn’t right.

Staff had completed safeguarding training however this was not effective, and staff did not put this into practice. We spoke to 2 staff members about the incidents, they were not aware that physical abuse incidents between people living at the service could or should be reported to the local safeguarding team for review.

Relatives did not always feel the service was safe due to the needs of people not always being met by staff.

There is more horror. People’s health risks were not well managed either. There was an absence of robust guidance relating to people living with epilepsy.

One person who was new to the service did not have any guidelines in place for staff to support them with their epilepsy.

People were at risk of not receiving their prescribed emergency epilepsy rescue medicine. Staff had not completed training to administer a specific medicine that is used when an epileptic seizure is prolonged. The guidelines in place for administering this medicine were not clear.

One staff member told us they would hoist the person during a seizure to assist them to their bedroom. Hoisting a person during a seizure could cause serious injury.

And you know what’s coming next don’t you…

We were not assured that people who were at risk of choking would be supported safely. One person’s care plan identified they were at high risk of choking and aspiration pneumonia, however the care plan contained conflicting information about how they should receive their nutrition. The care plan contained details that they needed a pureed diet but also information they should not have any nutrition orally but via their PEG.

There was no clear guidance in place to support people who became anxious or distressed. There were environmental hazards and risks and inspectors found medicines weren’t managed safely.

There were also insufficient staff in place, and despite the provider being paid to provide someone with 1:1 support, they were inspected to follow staff around as they did other tasks.

There was not always enough staff to meet the identified needs of people in the service. One person who was assessed as needing 1-1 support, was supported by a staff member throughout the day whilst they carried out other duties such as medication, paper-work and cleaning. We observed the person being taken around the service without meaningful 1-1 interactions whilst the staff member completed other jobs and supported other staff.

Inspectors also found there were insufficient numbers of staff providing support at night. They found a number of other failings, including unsurprisingly that the service was not always working within the principles of the Mental Capacity Act.

What is it like to live in this home?

Whilst we observed some positive interactions, we also observed interactions from staff that were not person centred. We observed people had very little to do. One person was interested in interacting with staff and was going from room to room for some interaction. However, staff had little time to interact meaningfully with the person. The provider told us they recognised this and will take action.

People were not always able to go out as and when they wanted. There had been no oversight of daily activities and it was not always clear from people’s daily notes, what activities they had been supported to take part in. One staff member told us, “They [people] are just sitting there. One person’s wheelchair doesn’t work properly.” One relative told us, “It was a lovely place but now it’s not. We don’t open the door to go outside because [person] would cause chaos.”

It must feel like people are under attack, lost in their own home, with no meaningful interaction or engagement. And is the provider alert to that? Do they care?

We were not assured that people and relatives were always able to, or felt comfortable to, raise concerns or complaints. The Regional Director told us there had been no complaints in the last 5 years and that feedback they had from relatives was positive. However, when we spoke with relatives, we also received detailed negative feedback about the service.

The service had an accessible complaints procedure in place for people. The topic of whether people were happy or not was discussed in key worker review meetings. However, one person’s review highlighted they were not happy but it failed to document any action taken to address this.

All performance. No care. The failing in the leadership section are awful, and plentiful.

There was not a person-centred culture in the service. The provider failed to identify a poor culture within the service. The provider did not have a robust system in place to identify the poor culture we found during inspection. For example, they had failed to identify some staff were not supporting people in a positive, person-centred way. This included how staff were referring to people and how they spoke about people they supported.

The provider had not ensured staff felt supported in their role. Staff told us they did not always feel supported by management, due to the changes of management within the home. One staff member told us, “We told management we couldn’t support [persons] needs but they haven’t supported us.”

The provider had not ensured the service was inclusive and empowering. The provider failed to ensure staff members supported people and spoke about people in a way that was empowering. One senior staff member told us, “Unless [person] is ‘screaming’ we know they are fine.” One relative told us, “It’s not just their safety, it’s their mental well-being and general health being affected.” Another relative told us, “The whole atmosphere has changed from calm and homely to virtual chaos.”

A staff member saying an effect of someone’s Parkinson’s was “for attention”, a senior staff member saying unless someone is screaming we know they are fine. This is not care. This is abuse in plain sight.

Next up a domiciliary care agency, working with 169 people at the time of inspection, PLL Care Services in Witney, Oxfordshire.

The inspection was prompted by concerns CQC had received about the safety of the service.

These concerns were around up to date and accurate records and assessments not being in place. There were also concerns about the effectiveness of the management in relation to governance by ensuring the service was safe and of a high quality. A decision was made for us to inspect and examine those risks.

The service was downgraded from good to inadequate as a result of what inspector’s found. The report makes for a harrowing read, I’ll just share the summary of lowlights:

Right Support: Robust safeguarding procedures were not embedded into practice. Concerns had not always been reported to the local authority as required and systems were not reviewed to minimise the risk of them happening again. Care plans and risk assessments did not always contain relevant, up to date information within them or were not available. Risks to people’s safety were not always identified or mitigated. Therefore, staff did not always have the information required to provide safe and effective care and in relation to people’s specific health conditions.

People did not always receive their medicines safely and referrals to health care professionals were not made in a timely manner. People were not supported to safely manage their medicines and did not always have access to their medicines. Topical medicines such as creams were not always documented adequately to ensure staff knew about these creams or where to apply them, and missed medicines were not always followed up by the provider.

People were not always supported by staff who had been safely recruited. Recruitment information
contained contradictory start dates. The provider completed police checks but could not always evidence they had gained references for staff prior to them starting work. Documents indicated that staff received an induction before working with people. However, we received mixed reviews from staff about their training.

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.

Right Care: Care was not person-centred and did not promote people’s dignity, privacy and human rights. Care plans were not person-centred and did not always contain information which would support staff to know the person they were supporting. Spot checks evidenced that people were not always treated with dignity. People and relatives were not always involved in reviewing of care needs.

Right Culture: The ethos, values, attitudes and behaviours of leaders and care staff did not ensure people using services led confident, inclusive and empowered lives. Effective quality assurance measures were not embedded to ensure a culture of continuous improvement. Audits and spot checks of staff competence had not been completed routinely and accidents and incidents were not reviewed to minimise the risk of them happening again.

The provider did not share information in an accurate or transparent manner. Numerous discrepancies were found between information given by the provider and details obtained from records, staff and other professionals. Discrepancies included basic details such as the number of people supported, how people’s care was funded and how many staff were employed. The provider had not notified CQC of safeguarding concerns as required by their registration. Feedback from people regarding the quality of the care they received was not regularly sought. Staff meetings were not used as a forum to share ideas and learning but as a way for the provider to share instructions. Staff did not receive regular supervisions to support them in their roles.

Next up we have Randomlight Ltd St Nicholas Care Home in Bootle, which sounds like it isn’t even pretending not to be a large warehouse or institution.

St Nicholas Care Home is a residential care home providing personal and nursing care to 93 people at the time of the inspection. The service can support up to 176 people within 6 buildings. At the time of the inspection however, 2 of the buildings were not in use. Of the 4 buildings operating, 1 provides specialist nursing care to people who have a learning disability and autistic people. This unit is known as Brocklebank House. Brocklebank House can accommodate 28 people. At the time of the inspection, 19 people were residing on this unit. The other units provided nursing and residential care to older people. Several people lived with dementia.

Wow, that must feel super homely, not.

The inspection was prompted in part due to concerns that CQC received about management of the safety of people
following an incident. It is never made clear in these reports what the ‘incident’ is and they are usually addressed separately, if appropriate to do so, which always leaves me wondering if things are much worse even than what it appears on the surface of the report.

This is what the inspectors found:

Right Support: The physical layout of the building was not homely or domestic in style. It was clear from the roadside people were living within a care setting.

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 experienced locked and inaccessible areas within their own home. The reasons for any restrictions were not based on people’s individual risk. Systems to oversee the application of authorisations to deprive people of their liberty were not sufficiently robust.

People were not supported to develop their independence skills, and everything was done for them. People were not involved in or encouraged to participate in the day-to-day home related tasks such as cleaning or cooking.

Right Care: Care was not person centred and people were not always being consulted before being provided with care. People’s communications needs were not always recorded and there was a lack of awareness of how to
apply national best practice supporting people with a learning disability and autistic people. Some inappropriate language was used when referring to people who used the service.

People were not always supported to make informed decisions about their care. Some care plans were brief and did not include information how to best support people. Effective systems were not in place to ensure there was learning from events which occurred at the service.

Staffing levels were insufficient in Brocklebank House to enable all people to access the community to pursue their leisure interests and form meaningful relationships within their local community. The activities available were of poor quality and care staff did not recognise planning social and leisure activities as part of their role.

Right Culture: The culture in Brocklebank House needed to be improved to meet the needs of people with a learning disability and autistic people. People were not given the opportunity to lead a fulfilled and valued life and experience high quality care.

Not all staff who worked on the unit had the appropriate skills and knowledge to support people effectively. When staff members did hold these skills, they weren’t always deployed in the most effective way. Most, but not all, of the improvements we identified were in relation to meeting the needs of people living in Brocklehurst House.

Frequent changes in management had impacted on the quality of the care delivered across the service in general. The provider had failed to put in sufficient measures to mitigate this risk. There was a lack of evidence of a commitment to continuous improvement.

Actions from previous inspections had not been sufficiently addressed. Although we identified significant improvements were needed, people across all units told us they were happy living at St Nicholas care Home. People received their medicines as prescribed and were supported to attend medical appointments when needed. Regular checks were made on the building and equipment to ensure they were safe to use.

We observed people receiving visits from family and friends and people’s bedrooms were welcoming and could be personalised to their taste. Staff members told us they felt supported in their role and all people we spoke with had confidence in the new manager who had recently been appointed.

If I had a pound for every time I’d read that people and relatives were satisfied with unsafe care in breach of their human rights, or better still for the number of times I’ve read that people had faith and confidence in a newly appointed manager… I really should go back and check how many times that faith is well placed, versus how many times they too leave/nothing changes. It’s so utterly painful reading these reports, time and again, and seeing the low expectation underpinning it all.

In March 2023 St Nicholas Care Home had been found to be in breach of regulations and requiring improvement. The provider completed an action plan saying how they would improve. Seven months later they remain in breach, and are now rated inadequate and in Special Measures. We’ll see what comes next.

Before we head onto somewhere new I’ll post a few quotes from the report to give you a flavour of what life must be like for people stuck there.

A person told us, “I can wait for what seems like hours to get to the toilet. It’s not their fault. There’s just not enough staff.”

People who lived in Brocklebank House were not all able to leave the service on a regular basis and access their local community because there were not enough staff to facilitate this.

There was a lack of appropriately qualified staff deployed in Brocklebank House. Nurses who held a specialist qualification in working with people with a learning disability and autistic people worked night shifts. They were not involved in the development and review of care plans so were unable to impart their knowledge.

Agency staff did not know the person they were supporting, nor understood the support they were about to provide. One agency staff member told us, “I don’t actually know” when asked the name of the person they were supporting.

People were restricted from accessing all areas of their home. For example, some communal areas were often kept locked and being used to store fresh laundry and equipment. The kitchen area in Brocklebank House was locked and stored staff personal belongings.

In another unit, bedrooms were locked when people were not in their room to prevent other people entering these rooms. However, risk assessments had not been completed to address this on an individual basis. People did not hold their own bedroom keys which meant they were not always accessible as people had to ask staff to open their bedrooms. [It sounds closer to a prison than someone’s home]

[Inspectors] observed staff did not always communicate with people, talked between themselves and swapped between people when assisting them with meals with no explanation.

People were not always assisted to eat where they chose. A person told us, “I prefer to go into the lounge for meals but sometimes they haven’t got the staff to assist me to get there, so I’ll eat in my room.”

Staff completed online and face to face training to develop their skills and knowledge when supporting people with a learning disability and autistic people. However, there was little evidence this training had been put into practice. [Mandatory training is not the silver bullet people think it is].

We observed a lack of positive interactions between staff and some people who used the service. People spend long periods with no acknowledgement or interaction from staff. We observed a person being supported from an area of their home in their specialist armchair. Staff gave no explanation to the person about where they were going or for what purpose.

Some of the language used by staff to describe people was not dignified. For example, people who needed assistance to eat and drink were referred to as ‘semies’ and ‘those we need to feed’.

Language used in care plans also needed to be reviewed as people were not always respected as individuals. For example, a person’s day was referred to as ‘a shift’. People were described as ‘suffering’ from their learning disability or medical condition. A person’s care plan referred to behaviours they displayed including ‘stealing’ food and ‘being caught’ entering the kitchen area. Another person’s finances were referred to as ‘pocket money’.

[Inspectors] observed a staff member walking around Brocklebank House with a set of keys attached to their waistband, which gave an institutional feel to the environment. [The power trip, the warder, the abuse in plain sight]

Care was not planned or delivered in a personalised way. The personal history of people was not always known. This meant people’s needs and preferences had not always been identified or recorded.

A person told us how their preference for female only care staff was not always met. They told us, “I don’t like men dealing with my very personal care and have told them about this but they [male care staff] still come into me and that really upsets me. It’s not dignified, is it?”

People were exposed to the risk of social isolation. Unless people received funding for additional 1-1 care, they were offered little in the way of meaningful activity and had no opportunity to go out and access their local community. Some staff who worked in Brocklebank House told us they could not recall the last time they supported people to leave the service.

Although there was an activity plan in place, people told us there was little to do. Comments included, “Nothing, we go to bed” when asked about evening activities. Other people told us, “I have been on this unit for a couple of months. Not been out yet but would like to” and “We used to have a music group but 2 staff left and it hasn’t happened since.”

CQC took enforcement action in the shape of warning notices.

Inspectors carried out a targeted inspection of Nayland Lodge in Colchester to see whether they remained in breach of regulations, having been in Special Measures since December 2022. This is what they found:

We found the provider had failed to respond effectively and promptly to our concerns; very little pro-active action had been taken to drive, embed and sustain improvement for people and stop previous breaches from continuing or re-occurring.

The service was not well-led. The provider failed to carry out their regulatory responsibilities and did not have adequate oversight of the service. They lacked recognition and understanding of risk and subsequently lacked robust assessments and controls to protect people and keep them safe. There was a high number of incidents requiring police intervention and a failure to identify and act on where things were going wrong.

There were no clear management systems followed in practice to ensure safe staffing levels. New and inexperienced staff members were not sufficiently supported to deliver safe and appropriate care. Learning and development was not managed and planned in a way that ensured staff had the opportunity to build on their knowledge base and develop their skills to carry out their roles and meet people’s specific need.

The report is littered with examples of non-care and chaos. It starts with this:

There was a failure to recognise and understand the root cause of people’s heightened behaviours and deterioration of their mental wellbeing. In some cases, actions taken by the provider and manager impacted on people’s mental health. For example, serving warning notices of eviction instead of providing the right level of support.

It has this to say about safeguarding:

Safeguarding incidents were not well managed or appropriately reported. There was a culture in the service of not recognising incidents as safeguarding concerns and alerts to the local authority and statutory notifications to the Care Quality Commission were not appropriately made. No pro-active actions or lessons learned arose from incidents which meant there was always a risk of them reoccurring.

People and others were not always kept safe from the risk of harm because staff were not being given the training that enabled them to meet the needs of, and/or effectively safeguard people. Staff continued to tell us they were not equipped to manage people’s distressed behaviours that posed a risk to themselves and others.

Since our last inspection the manager had completed training to become a trainer to deliver de-escalation training and physical intervention training to staff. Staff confirmed the manager had not delivered this training to them. The manager told us they had not had time to deliver the training, nor did they feel sufficiently competent to do so.

We heard that people were not receiving the hours that commissioners had agreed to fund to allow them to have a life. Which unsurprisingly, in turn, caused them harm. 21st century care.

The level of staffing and shift patterns were not linked and determined by people’s support needs and funding arrangements. People were not receiving their additional funded support hours to ensure they led fulfilled and meaningful life. This impacted on their mental health and heightened their stress and anxiety which placed them at risk of harm.

The lack of leadership is something else.

At our last inspection we rated this key question inadequate. This meant there were widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The provider had failed for the last 4 consecutive inspections to establish and effectively operate systems and processes to assess, monitor and improve the safety and quality of the service provided to people. This placed people at risk of harm. This was a breach of regulation 17(1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The purpose of this inspection was to check if the provider had met the requirements of the warning notice we previously served. Not enough improvement had been made at this inspection and the provider was still in breach of Regulation 17. The rating remains the same inadequate.

I’m not really sure how your leadership can be considered to be so woeful for 4 consecutive inspections, and you still be allowed to run a service really.

The provider had not ensured legal requirements were met. We identified notifiable incidents that had not been reported to CQC in line with the provider’s legal responsibilities; we were not assured they had all been referred to the local authority safeguarding team.

The service has not had a manager registered with the Care Quality Commission for nearly 6 years. Whilst there was a manager in post, they also managed the provider’s other care home. This meant Nayland Lodge lacked the consistent, visible management it needed to drive, embed, and sustain improvement.

No registered manager for 6 years. What is the point of having this as a requirement if you can flaunt it, so barefacedly, for six years without sanction?

The local authority had placed a suspension on commissioning new placements with the service, to enable them to address improvement. There was a reluctance to take up offers of support from the local authority quality improvement team and very little improvement was seen.

Professionals told us they did not always receive accurate information from the service which did not enable effective working in people’s best interests.

There was no evidence to demonstrate the service had engaged in local and national forums or development groups which would assist in gathering best practice knowledge to support improvements in the service in relation to mental health, learning disability, autism and hoarding.

Surely, surely, as I write and you read, CQC are closing this place down?

Just two more reports to cover in October, it’s not all that was published, but its all I can face. Both are domiciliary care agencies.

First, Michael Batt Foundation in Plymouth.

The inspection was prompted following a series of incidents that led to harm to someone using the service. CQC had intended to conduct a focused inspection on a couple of domains but once they started they expanded it to a full inspection.

The inspection was prompted in part by information shared with CQC about a series of incidents which a person using the service sustained a serious injury. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of the incident. However, the information shared with CQC about the incident indicated potential concerns about the management of risk, MCA, and unlawful restraint. This inspection examined those risks.

We undertook a focused inspection to review the key questions of safe, effective and well-led only. However, further concerns and risks were identified so a decision was made to carry out a comprehensive inspection to include the key questions caring and responsive.

Inspectors identified breaches in relation to safe care and treatment, safeguarding people from abuse, consent, dignity and respect, person centred care, notifications of other incidents and governance.

Right Support: The Model of Care provided by The Michael Batt Foundation was not safe. 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. Care plans and risk assessments relating to the health, safety and welfare of people were not kept under regular review. Some peoples risk assessments were outdated and did not reflect their current risk to themselves and/ or others.

People were placed at the risk of not receiving safe care as there was not an effective structured system to ensure staff had been deployed effectively. Medicines were not always managed safely and in line with the National Institute for Health and Care Excellence (NICE) guidance Managing medicines for adults receiving social care in the community.

Right Care: The Model of Care provided by The Michael Batt Foundation was not person-centred and did not promote people’s dignity and human rights. The language sometimes used by staff to describe people within their care notes, was outdated and disrespectful. Staff were able to describe the actions they could take if they had safeguarding concerns for the people they supported. However, records showed appropriate action had not always been taken.

There was an absence of a person-centred care planning review process, and we could not be assured that peoples care plans were up to date and contained sufficient information to guide staff in providing good quality personalised care. People were not supported to live their lives according to their preferred routines. There was a lack of sufficient evidence to show that all reasonable steps had been taken to re-engage people in meaningful activities and social interactions following the COVID19 Pandemic.

Right Culture: Restrictive practices, poor application and understanding of the Mental Capacity (MCA), a lack of openness and transparency and inadequate governance and oversight had helped to create a ‘closed culture’ at The Michael Batt Foundation. 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.

It was evident from a review of the data and information held by the provider and our findings throughout our inspection that staff did not receive regular, effective supervision and support. The registered manager was aware of their regulatory responsibilities such as submitting statutory notifications but failed to carry this out.

The findings of our inspection identified a culture that was not based on learning. This meant that when things had gone wrong, the potential for re-occurrence was inevitable because there was no action taken to review, investigate and reflect on incidents.

Michael Batt Foundation was found to be inadequate and has now been placed in special measures. What must it be like for people receiving support from them? A few quotes from the report:

The findings of our inspection identified a culture that was not based on learning. We saw one example we saw evidence for one person there had been repeated avoidable incidents within the community. This meant that when things had gone wrong, the potential for re-occurrence was inevitable because there was no action taken to review, investigate and reflect on incidents.

We reviewed 3 peoples care records and identified all 3 people were being unlawfully prevented from leaving their homes. The provider and local authority confirmed that no applications had been made to the Court of Protection to authorise the deprivation of these 3 peoples liberty. This meant there was no legal basis or framework in place to support these restrictions. This failure meant that peoples human rights were not always upheld.

Although relatives described staff as extremely caring, the language used by staff to describe the people they cared for within people’s care notes was disrespectful, or showed they were not always valued. For example, care records described people as using ‘Vile talk’, being ‘delusional’, ‘demanding and rude at times’ and ‘negative and constantly talking’. This meant that people were not always treated with dignity and respect.

People were not supported to live their lives according to their preferred routines. Relatives told us there was a lack of meaningful activities. Comments included “(Person) use to do so much, they don’t do much now. It’s all dried up”, “(Person) hasn’t been offered (activity) for a while. I don’t think they realise how important it is to (person) and the positive impact it has on them’ and “(Person) use to (social activity), they don’t even offer it anymore” and “Some staff try and get involved with (person) others just arrive and sit in the other room and do nothing until it’s time to go”.

The registered manager was registered with CQC in December 2020 and the service has deteriorated from good to inadequate within this time. The concerns we identified in relation to safeguarding, medicines management, accidents and incidents, and person-centred care were all systemic from a lack of robust leadership, governance and effective oversight. This helped to reinforce a culture where there was an acceptance of situations and quality of life which would not be acceptable for most people. This was not in line with guidance contained in Right Support Right Care Right Culture.

There were no formal governance systems in place. This meant the providers oversight and governance of the service was inadequate in identifying failings in relation to the quality and standard of the service they provided. This meant the provider was out of touch with what was happening within The Michael Batt Foundation.

Isn’t it funny how providers manage to be so out of touch with the reality for people enduring their services, but never out of touch with invoicing for their fees.

Finally, Sentricare Birmingham. Inadequate in every domain.

And not for the first time. They were found to be inadequate in every domain in January 2023:

They were also found to be inadequate in every domain in July 2022.

In July 2022 when they were first rated inadequate, there were 282 people using the service. In January 2023 the provider told CQC they were only supporting 12 people.

At the time of our inspection the provider initially told us there were 12 people using the service. However, due to information being shared with us by a whistle-blower, we later established we had been provided with incorrect information by the provider. Based on additional information shared with us by the provider, they provided a list of 88 people using the service. Again, during the inspection, we found this number was incorrect and had increased to at least 92 people using the service. We are still seeking clarification from the provider to establish the accurate number of people using the service.

In August 2023, the provider told CQC 76 people were using the service. This most recent inspection was conducted to follow up on actions the provider was due to take following previous inspections. Inspectors found them to still be in breach of multiple regulations.

We have identified continued breaches in relation to; Regulation 9 – Person centred care, Regulation 10 – Dignity and respect, Regulation 11 – Need for consent, Regulation 12 – Safe care and treatment, Regulation 13 – Safeguarding service users from abuse and improper treatment, Regulation 16 – Receiving and acting on complaints, Regulation 17 – Good governance, Regulation 18 – Staffing and Regulation 19 – Fit and proper persons employed, Regulation 20 – Duty of candour at this inspection.

In terms of what things were like, I’ll share the overall summary:

Right Support: We continued to be told people were not always supported to have maximum choice and control of their lives and they were not always involved in care reviews. Some people told us concerns they had raised these had not been addressed. Staff did not always support people in the least restrictive way possible and in their best interests.

We found guidance within some people’s care plans for staff members to follow when supporting autistic people or people with a learning disability who may express distress or frustration, had improved. Care plans and risk assessments in how to respond to such expressions did provide staff with information on how to respond, how to de-escalate for some people but not others.

Staff training and record keeping needed to be improved in relation to the Mental Capacity Act 2005 (MCA).Right Care: People’s care, treatment and support plans continued to not always reflect their range of needs or promote their wellbeing and enjoyment of life.

People who were known to express anxiety did not have proactive behaviour strategies documented in their care records. This meant they lacked detail on the specific actions staff should take to ensure practices were least restrictive to the person and reflective of a person’s best interests.

Right Culture: Care was not always person centred and people were not empowered to influence their care and support. Governance systems remained inadequate and not ensure people were kept safe and received high quality care and support in line with their personal needs.

At the last inspection the provider’s oversight of the service had not identified some of the shortfalls we found during the inspection process as part of their audits and checks. At this inspection this continued. Systems in place for managing complaints, safeguarding concerns, accidents, and incidents were not robust or effective. Not enough staff members were deployed by the provider to support people.

The main complaint raised by people and their relatives continued to be the length and inconsistency of their care calls. Staff who attended people’s homes remained inconsistent at times and for some staff their ability to communicate with people and their relatives was restricted due to language barriers. People were supported by staff to take their medicines, however, guidance in place continued to not always be clear for staff to follow. Staff did receive an induction when they started work but some people continued to tell us they felt staff members did not have appropriate skills and knowledge to support them how they wished.

Care plans and risk assessments continued to lack robust and clear guidance, with incorrect or conflicting information. Risk assessments continued to fail to direct staff on recognising symptoms of known health conditions. People continued to tell us their care and support was not always planned in partnership with them, and persons close to them.

And what did that look like for people receiving their care and support from Sentricare, some quotes from the report:

People were at risk of abuse and were not consistently protected from harm. Lessons had not been learned. At this inspection we continued to find, multiple safeguarding concerns had not been identified, reported, or actioned robustly.

At the last inspection improvement was required to ensure people’s care records identified the level of support they needed from staff with their medicines. At this inspection we found the same concerns. Care plans and risk assessments contained conflicting or inconsistent information to guide staff on the level of medication support people needed. This was unsafe and continued to place people at risk of not receiving their medicines, as prescribed. The provider had failed to make improvements to ensure people received their medication as prescribed. This was due to care calls taking place at much later than scheduled or had been scheduled too close together. Continued poor or inconsistent administration of medicines could have long term effects on people’s health conditions.

Records showed some people’s care calls continued to last for less than half of the required time. These records also demonstrated that some staff were recording they were in attendance of 2 calls at the same time, meaning these records were incorrect. For many people using the service we found they frequently received late calls or even early calls.

At the last inspection staff told us, and records confirmed people who required 2 staff to support them safely often only 1 member of staff attended their call. At this inspection records indicated this poor practice still occurred as staff logged into care calls at different times, so were not in attendance together. This meant people were exposed to the risk of harm as the provider had not identified this was occurring.

Staff continued to tell us their allocated rotas did not always include travel time between calls, or more than 1 care call was scheduled at the same time. Rota’s, we looked at confirmed this. This meant calls would either be shortened or late, impacting on the standard of support people received. This had resulted in some missed calls.

Travel time and the full allocation of time staff needed to provider care and support was not factored into their rotas. Some staff members continued to tell us they were concerned to raise issues about their rota’s as they feared they would not be paid or would lose their jobs. For 1 staff member, the provider had unsafely scheduled 36 care calls between 05.50 and 23.00hrs. If all calls were completed for the correct amount of time this should have taken the carer 20.5 hours to complete. This did not include, any travel time, breaks and calls were scheduled to overlap. This meant people would receive short, late or missed calls to ensure all calls were undertaken.

The provider was not compliant with the MCA. For people who were unable to make their own choices and decisions, the provider had still not obtained evidence, that those making decisions on their behalf had the necessary legal authority to do so. This meant the provider could not assure themselves people were being supported in the least restrictive way and decisions were not being made on their behalf inappropriately.

We continued to have concerns in relation to the registered managers understanding and application of the MCA. We found the required principles of the MCA were not consistently applied and where mental capacity assessment had been completed these were not decision specific. For example, for 1 person, the registered manager had recorded, ‘they do not have full capacity because they have slurred speech and struggles to make sensible statements’.

Other people and relatives continued to tell us they felt rushed by staff which meant they did not get their support in a dignified and respectful way. One person told us when asked if the staff stayed the full time, “I feel extremely distressed and anxious, it [the call] should be a 30 minute call and they are gone in 10 minutes. They do not give me a choice of anything. I tell them not to bang the door and they seem to bang it even louder when they leave.” At the last inspection the registered manager assured us they would address these issues. That had not happened.

Some people and their relatives continued to tell us care plans were not always developed with their involvement and their relatives had never been asked about their care needs and wishes. One relative told us, “[Name] the registered manager came back about a week ago to try to get us to sign paperwork. I sent him away a while ago as he was shoving the contract in my face.”

One person was unable to communicate verbally to indicate their needs, wishes and feelings. We found they now had a communication passport which informed staff how to recognise if the person was happy, sad or in pain. The passport referred to a book containing small pictures to help identify what the next task they would be doing. Feedback confirmed that although the book was available, it was not used to communicate with the person. This meant information in care plans and supporting documents was incorrect.

The culture at the service was not inclusive or supportive. Some staff spoken with told us they found the registered manager unapproachable, but others felt they were supportive. Some staff and people referred to the registered manager as a ‘bully’. Some staff told us they were fearful of approaching the registered manager about their rota as they were threatened with having their hours reduced. Similar allegations of such behaviour have been raised by staff at previous inspections.

The state of so called care and support. The only glimmer of light on the horizon is that I know CQC have been taking action against Sentricare for some time and there is a five day hearing at the Care Standards Tribunal next month. Will see where, if anywhere, that leads.