September’s deathmaking

Eighteen months ago, in July 2022, I started curating on this website reports published by CQC into care and support for learning disabled and autistic people, that was rated as outstanding or inadequate. In this post I’ll share some of the recently published low lights.

One of the things I feel that needs acknowledging before I get into the detail though is that CQC really appear to have upped their game. The inspection reports are worlds away from what they used to be, the things that inspectors are seeking out and observing truly reflect what people need for a good quality of life, and the regulator is holding people to account for what they promise, not just what they deliver. Even when a provider is not supporting autistic or learning disabled people, if they are registered to do so, they will be assessed against Right support, right care, right culture, which opens with this:

Autistic people and people with a learning disability are as entitled to live an ordinary life as any other citizen. We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for

One such example was Perfect Care Solutions UK Ltd, a domiciliary care agency in Dartford, Kent. They were not currently supporting anyone autistic or with a learning disability, but they were registered to do so. The service was registered on 3 October 2019 and this was it’s first inspection. This was a full inspection and they were rated as inadequate on four domains: safe, effective, responsive and well-led, and inspectors found insufficient evidence to rate them on caring.

Inspectors planned to conduct some aspects of the inspection remotely and gave the provider notice of the inspection to facilitate that. When they didn’t get the information they required, they switched from a remote inspection to an in-person inspection. The inspection activity took place between 11 May and 18 June 2023, and they visited the office on 17 May 2023.

The three inspectors found every aspect of the service to be inadequate. They made a safeguarding referral during their inspection due to potential abuse they had identified. There had been no pre-employment checks or references collected for staff and inspectors could not be assured that DBS checks had been conducted. There were no care records and medicines weren’t managed safely. There was no system in place to ensure lessons were learned from any incidents to reduce risk of future harm. There were no holistic assessments of people’s needs, no care plans, no records of their choices. Staff received no induction or ongoing training. Records relating to nutrition and hydration were missing or not fully completed. People’s care was not delivered in line with the Mental Capacity Act and staff had no training in the MCA. There were no records of capacity assessments. People were not supported with their health needs and there were no records of timely refer to healthcare services, or partnership working with other services. As well as a lack of care plans or care records, there were no assessments of people’s communication needs and no evidence of staff providing information in a way that people understood. The provider had no complaints policy or process.

The provider and the registered manager were not aware of their legal responsibilities and did not ensure the service was meeting the regulations. During the inspection we identified serious concerns in relation to risk management, safeguarding, staff recruitment, infection prevention and control processes, care planning and assessments, staff training and lack of quality assurance systems.

CQC’s response to the state of this was to take action and cancel the provider’s registration. The service was archived on 6 December 2023 and at that point ceased to be registered with CQC.

So what horrors have been revealed in the last few months, in relation to providers who are actually (supposedly) providing care and support to autistic and learning disabled people? And what does that tell us about what the reality is for far too many people and their lives? I’m going to start in this post, with reports published in September 2023.

Many providers are quick to push the line that it’s a lack of staff prepared to work for low pay and poor status that is crippling social care provision. First up I’ll share Living Ambitions in Surrey who were rated inadequate in September 2023 (following a November 2022 inspection). With such an ambitious name, you’d hope that life in their care home would be lively and vibrant. It’s a residential care home for people with a learning disability, registered to provide care for 6 people but at the time of inspection there were only 5 people living there, one of whom was in hospital. What did inspectors find?

There was high level use of agency staff but the provider did not provide them with any induction, so they didn’t know people’s needs or preferences or how to support them.

Staff cared about the people they supported but were frustrated by their inability to deliver person centred care because of the provider’s failings. People’s care records were in disarray. People’s weekly activity timetables did not accurately reflect what they did. This is because the timetables were out of date and there were not always enough staff available to support people to do the things they wanted to. Staff received training but they did not receive supervision or appraisal.

Yet more evidence why mandatory training is meaningless if it is not situated within a culture of improvement, and a fundamental understanding of the humanity of all people. Training is a tickbox in the absence of ongoing support and development.

The provider failed to promote the right culture at the service. Staff were stressed and demoralised having been through a period when the service had no management at any level. This included the failure by the provider to ensure a manager, deputy manager, senior support worker, shift leaders or keyworkers were in place. Staff described the multiple safeguarding alerts raised during this period as “inevitable.” Staff felt “abandoned” by the provider’s leadership as they struggled to maintain the service which was short staffed. This resulted in staff working many additional 14 hour shifts, with one member of staff working 300 hours in one month to protect people from the risk of neglect and the failure of the service to provide basic care and support. The provider’s leadership failed to demonstrate the values and attitudes expected of them by people, their relatives, staff and healthcare professionals.

The provider had temporarily redeployed one deputy manager from another of its services to address the wide range of serious and immediate problems at the service. This inadequate level of response further demonstrated the provider’s lack of urgency in ensuring people’s safe care and treatment.

Just imagine the desperation of those staff, the good ones, the ones that care. Inspectors found that people were not always protected from foreseeable harm. There were no risk assessments relating to any aspect of health, care and support for two people.

People who were identified as being at risk of swallowing unsafely were not always safely supported. One healthcare professional told us there was poor practice around supporting people to eat and drink. Another healthcare professional told us they had asked for a coughing chart to be kept for one person, but despite a second request, this had not happened and was still not in place. Coughing charts are used to identify where people maybe swallowing unsafely and risk inhaling foods or liquids into their lungs. The provider’s failure to monitor people’s risk of aspirating meant healthcare professionals did not receive the important information they required to assess and plan around people’s safety.

How many more deaths are needed before care providers take risks of aspiration seriously? We know that aspiration pneumonia is one of the most common, and preventable, causes of death for people with a learning disability, and yet care providers are indifferent to the basics.

People were at risk of malnutrition, and when the charger for the weighing scales went missing in the home, the provider didn’t bother to replace them. The apathy and indifference, to even the basics.

Two people in the home had no assessments or care plans. How could people possibly think they were supporting people to live their best lives, without knowing anything about them? How is this possible? Where are these people’s social workers? Where are the commissioners? Why is it left to the regulator to uncover this non-care?

Given the apathy and chaos already described, I’m sure you’ll not be surprised to hear the provider had failed to ensure that staff were able to respond to a fire incident. There was no weekly fire alarm test, no drills, personal emergency evacuation plans were in place but hadn’t been reviewed.

Another example of why the requirements eg for all people to have a personal emergency evacuation plans, does not in and of itself lead to good or even safe practice.

People were at risk of financial abuse:

All staff (permanent, bank and agency) could access the keys to the service’s safe within which people’s monies were kept. In addition, the service did not operate a system of regular physical checks of people’s cash or checks of financial transactions and receipts. When people’s money went missing this was raised as a safeguarding alert and the police were informed of the theft. The provider reimbursed people for the amounts stolen.

People were at risk of infection, and staff were not following the enhanced cleaning required following covid. Medicines weren’t managed safely and were not audited. Not all staff were trained to administer medicines appropriately.

Systems were not in place to safeguard people from abuse and incidents were not recorded or reported appropriately.

The service had an incident form folder to record when people had sustained injuries. However, not all accidents and incidents were recorded in it. For example, health and social care professionals informed us about injuries sustained by people which were not recorded in incident logs. Indeed, there was only one entry for 2022. This failure to adequately record, track and analyse accidents and incidents meant the provider was unable to identify changes in people’s risks or take action to reduce them.

Staff told inspectors that they had complained over and over but that they became fearful of “becoming a target”. Staff did not know about whistleblowing procedures.

Where people had care records in place these were out of date and in some cases contained inaccurate information. For example, one person’s care record stated they could not use speech and had no communication needs. This contradicted the assessment undertaken by three health and social care professionals which stated the person could use limited speech and had high communication needs. This meant the person was at risk of not having the needs and preferences met because of the provider’s inaccurate care records.

Can we just pause a moment and take in what the care record said… that someone could not use speech and had no communication needs. Sorry, what? If you do not use speech, surely, surely, that is an indicator that you have a high level of communication needs, because how else would someone communicate? I’m reminded of the question my partner asks me on repeat, is it incompetence or is it malice. I’m not sure it really matters when the ignorance is this great.

Where healthcare professionals had provided advice, such as swallowing and thickening of foods and drinks, they had also witnessed this not be followed. People were sent to hospital without their hospital passports or health action plans. When does such apathy actually get called for what it is, wilful neglect?

Yet another reminder, if we needed them, that all the initiatives and paperwork in the world wont keep you safe, when no-one takes it, or reads it. We get so blind sided by having something to hold onto, and actions for people to take, and yet within it all people’s humanity is lost some how. There’s a very old blog post from me, reflecting on hospital passports and inquest exploration of them here.

There is a lot more about staff and the failures of leadership in the report, but the point I’ll finish on is another basic. It’s about humanity and dignity and seeing people as fully human. The bullet point before this one highlighted the fact that neither the communal bath or the ceiling hoist worked, so one person’s only options was to have bed baths, because the provider hadn’t bothered to get them fixed. Then this. I just can’t even comment really, it’s so horrific, just imagine if this was your reality, in your home. Social care in 2023.

The communal toilets in the service did not have toilet seats. This meant people were required to sit on cold and uncomfortable porcelain. We were informed that toilet seats had been removed to prevent people’s fingers being trapped. We were not shown risk assessments supporting this decision.

This report was only published in September, but was from an inspection the previous November. The CQC website report that checks are ongoing so I guess the next report will make clear what action was taken.

Finally, for your information, you may be fooled into thinking that Living Ambitions were a relatively small or medium sized provider, with just 17 services registered with CQC… but all is not as it seems and Living Ambitions are actually an offshoot of Lifeways, who describe themselves as “the UK’s largest supported living specialists”. Those providing care to Thomas Rawnsley, when he died, aged 20. Their staff told the inspectors that they felt abandoned by their managers:

One member of staff told us, “We had no management for two months or more. We were on own with no support at all.” The issue of short staffing was particularly acute during this period. One member of staff member said, “We were abandoned and demoralised and some staff lost their discipline. Some stopped coming to work. They would cancel their shifts; not sick, they would just say they were not coming in. It was so stressful, and the senior managers did nothing.” Another member of staff told us, “We had to work overtime because we care about the people.” This meant people were supported by insufficient numbers of tired, stressed and unsupported staff.

What other large providers, national names, were inspected and found to be inadequate in September 2023?

Well there was Leonard Cheshire St Michael’s Care Home with Nursing Physical Disabilities in Somerset. They had two targeted inspection reports published in September. The first was following an inspection in June 2023 which had been prompted by the unexpected death of someone using the service. Inspectors found that other people were at risk of choking “because people’s care plans and risk assessments had not been regularly reviewed and updated”. They also found incidents where staff did not follow the Speech and Language Therapy guidance that was in place for people.

The service had been rated as inadequate and placed in special measures prior to that following an inspection in March 2023. The March inspection had raised concerns about PEG feeding and staff knowledge and training around choking.

The most recent targeted inspection found that Leonard Cheshire remained in breach in relation to Regulation 12 (Safe care and treatment) and Regulation 17 (Good Governance). They found that concerns around PEG feeding remained, five months after CQC inspectors had put your service into special measures and raised concerns, and in the intervening period someone had died in your service, unexpectedly. Some staff reported that despite attempts to improve things, they still felt unsafe.

“No, it doesn’t feel safe, but we’ve [staff] stayed for the residents, I do speak up, because I don’t feel it’s safe.”

I wish these staff were the ones that were celebrated, and listened to, not the so called ‘leaders’ of providers that are failing them, and the people they are meant to support.

Inspectors found that medicines continued to not be managed safely.

For example, 1 person had been given 1 of their medicines at 14.00 hours on 30 July. They had missed 2 subsequent doses because there was none in stock. Records showed staff had carried out a stock check of this person’s medicines on 28 July 2023, but there was no record of staff ordering more medicine to prevent the person not receiving them on time.

The apathy and indifference.

Leonard Cheshire state on their website “We believe in building a fairer, more inclusive society. One that recognises the positive contributions we all make”. Yet, they don’t seem to believe in infection control, or basic cleanliness:

At the focused inspection in March 2023, we noted that the environment was not always visibly clean. Some people had bed rail covers on their beds, which were marked, and some were ripped. This remained at issue at this inspection. One person’s bed had been stripped, and there was a ripped pillow in place, which staff had not disposed of.

Although there were cleaning schedules in place, these had not been signed every day. A staff member said, “There is supposed to be 1 housekeeper on every day,” but cleaning records did not show this was the case. There were gaps in records that showed bedrooms, toilets, dining room and corridors were not cleaned on a daily basis.

It was unclear how cleaning was monitored in the service.

Inspectors identified ongoing concerns about staff understanding risks to people (this is months after an unexpected death in the service) and safeguarding concerns not always recognised or escalated leading to further avoidable incidents.

For example, food intake records for a person with SALT guidance in place showed the person had been eating food they had been assessed as not safe to eat, which indicated that staff were either unaware of the guidance or did not have a good understanding of what the guidance meant.

How many more unexpected deaths would there need to be in this service before people did develop an understanding? How does it require inspectors to highlight these failings? There were also ongoing concerns around communication and handovers.

Last year I reported on the second inquest into the death of Peter Seaby, who died from aspiration pneumonia, whilst under the care of The Priory. If you’ve time you can read the coroner’s conclusion here, and spot the similarities to what is clearly happening at Leonard Cheshire St Michaels, and possibly at Living Ambitions in Surrey too. When we know the risks and likelihood of people with a learning disability living with swallowing difficulties, and we know that aspiration pneumonia is a leading preventable cause of death, how is this so?

Achieve Together, are another large learning disability provider. They claim on their website that they are one of the UK’s leading providers, and that they have over 25 years expertise.

Our team of expert practitioners is proud to deliver high-quality support to over 2,300 people in almost 420 local care homes and services across England and Wales. We 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. Our goal is to drive quality across the sector and lead by example.

Big claims. I’ve written about this provider before Achieve Together… award winning specialist care, that CQC consider to be inadequate and Achieve Together… failing again. I am often contacted by staff who work for this organisation, sharing their concerns and reports of more poor care.

Remember, their goal is to the “drive quality across the sector and lead by example”, so what did CQC inspectors find when they visited Achieve Together Arundel House – Frinton-on-Sea? A bit of background. This service was registered with CQC on 10 October 2020 and the first inspection of it took place in January 2023. It was immediately placed in special measures having been found to be inadequate.

At this inspection multiple examples of unreported abuse were identified by inspectors. One person had “multiple events of unexplained bruising” and an “accident and incident record detailing an allegation of abuse against a staff member had not been escalated”. No safeguarding, no oversight, no follow up.

Given what I said above about choking risks, its perhaps unsurprising that some of the 10 residents there were also at risk.

An accident and incident record detailed an incident of choking of a person living at the service. The manager had not recognised this as a safeguarding incident and therefore did not make a required referral to the local authority.

Inspectors found there were insufficient staff on duty, despite the service being commissioned to provide a higher level of service. Why are commissioners not auditing and identifying this themselves? How much money is being paid to large providers, who are not actually providing what they’re being paid to do?

People were at risk of harm due to insufficient staffing, never mind at risk of non-lives.

The manager told us of the staffing levels they were commissioned for. This included where people were in receipt of 1 to 1 and/or 2 to 1 staff support. The manager was unable to provide evidence of how or if the time was being utilised.

Staff members told us the service did not have enough staff to support 1 to 1 and/or 2 to 1 activities. The manager was unable to evidence how dependency levels were considered in determining staffing levels and their deployment at the service. There were insufficient numbers of staff to adequately meet people’s needs.

Inspectors found that 55% of face to face training had not been completed, which the provider blamed on covid, however they also found not all staff were up to date with mandatory e-learning training.

Then there’s the detail of how the non-lives actually look and feel on a daily basis. People parked in front of a loud TV. This is not a life.

Staff did not always ensure people were protected from exposure to any environmental factors they would find stressful. One person, whose care plan detailed a sensitivity to a loud television or radio, spent most of the day in the main lounge where the television was turned up high.

There was more about the TV as sedative:

During our inspection we observed people sitting in the lounge with the television on and very little to do. People became agitated with each other and shouted at each other. One person told us, “I give up, can’t do a thing today, don’t go anywhere, don’t do anything.”

We asked staff whether the channel was what people wanted to watch. Staff told us [name] loves quiz shows and it keeps [name] quiet. This meant we were not assured people using the service were stimulated to improve their physical and mental well-being or that their choices and preferences were respected.

Remember Achieve Together claim that they “ensure that the people we support have every opportunity to fulfill their potential” [that’s their typo/spelling error so I’m leaving it as a direct careless quote]. What does that look like for the 10 people living in Frinton-on-Sea?

People were not always supported to engage in activities which were socially relevant to them. The activities plan displayed on the communal notice board included activities such as talking to other residents or watching television. This meant we were not assured the model of care within the service promoted people’s wellbeing.

People new to the service had not been added to the activity timetable and people who had died had not been removed.

Careless non-lives, and paid for by the tax payer too.

The local authority paid additional money for people to have specific hours of staff support for activities each week. However, there was no evidence provided to show whether people received their agreed hours and how their time was being spent.

When inspectors returned to Arundel House, six months after it had been placed in Special Measures and deemed inadequate, you’d expect a provider who claims to pride itself on quality and leading the sector, to have turned things around.

By now the ten residents had reduced to eight. This targeted inspection was considering the failing areas identified six months earlier: safety, risk, management and governance. Inspectors found “the provider did not have effective oversight and governance to drive improvement in a timely way and breaches of regulation continued”.

Since our last inspection the providers management arrangements had irretrievably broken down. Overall quality and safety were not being addressed. This included staffing, training, governance, and risk management which all directly link to a lack of effective leadership.

Irretrievably broken down. Remember the goal of Achieve Together to “drive quality across the sector and lead by example”.

Right Support: People did not receive the right support to maximise their choice, control, and independence. There were not enough staff to meet people’s assessed needs and commissioned support arrangements. This meant people did not lead fulfilling and meaningful everyday lives. The model of care did not focus on people’s strengths or promote what they could do. Limited information was available about people’s aspirations and goals and how staff could support them to achieve these. People did not receive an interactive and stimulating service.

Right Care: People were not consistently supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support good practice. Gaps in staff training, supervision and competency checks did not ensure people were cared for by staff with the necessary skills, knowledge, and expertise to deliver the right care and support. Care delivered was not person centred and did not promote people’s dignity and independence.

Right Culture: The culture of the service did not empower people to lead their best life. Leaders and care staff did not demonstrate values, attitudes and behaviours that ensured people at Arundel House led confident, inclusive, and empowered lives. Staff were unable to demonstrate their understanding of ‘Right support, right care, right culture’ guidance and how this should influence the support people received. The service had lacked leadership and direction. Governance systems were not operated effectively and failed to identify risk and people were not receiving a safe quality service.

The report also contains the information that after the last inspection, the one that found the home to be inadequate and placed it in Special Measures, Achieve Together could not even be bothered to do the basics.

The provider failed to complete 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 had not made enough improvement and remained in breach of regulations.

We are told that there has now been a change in management and the regional manager is overseeing things. Time will tell.

Another large specialist provider with a service rated inadequate was SENSE. Their home, Tanglewood, for up to 7 people in Malvern, Worcestershire was found to be inadequate by inspectors following an inspection in June and July 2023.

The inspection was prompted due to concerns being raised about restrictive practices and it 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. Staff were carrying out restrictive actions with people that was not in line with the assessed needs.

Right Care: Care was not always person-centred and did not promote people’s dignity, privacy and human rights. Safeguarding procedures were not followed and appropriate action had not been taken to protect people from abuse and poor care. Care was not always delivered in line with standards, guidance and the law.

Right Culture: The ethos, values, attitudes and behaviours of leaders and care staff did not always ensure people using services lead confident, inclusive and empowered lives. The systems for reporting were not always open and transparent. The provider’s governance systems were not effective. Governance systems did not ensure people were kept safe and received a high quality of care and support in line with their personal needs.

A number of Warning Notices were issued by CQC as a result of identified breaches in relation to safeguarding people from abuse, person centred care, management of risks, safe premises and management and governance of the service.

The report tell us that a whistleblower had contacted CQC about potential abuse at the service. It also tells us that the provider “had systems in place to safeguard people from the risk of abuse including the training of staff in how to recognise and report abuse” but of course if there is anything we should know by now, it’s that tickbox process isn’t enough. Despite these systems existing staff were not applying them effectively, leaving people at risk of avoidable harm.

The registered managed[typo assume manager] had not taken action to investigate concerns staff raised regarding poor and abusive treatment of people using the service. For example, a whistle-blower had raised concerns to CQC regarding potential abuse regarding abuse to people in the service, this information was shared with the registered manager for them to investigate and take appropriate actions. When we inspected no action had been taken to mitigate the continuing risk of harm to people.

One person’s records showed they had been restrained by 2 members of senior staff during a care task. Their records showed the person had resisted but the use of physical force to complete the care task continued. This was not in line with their assessed needs and did not reflect an approach that considered least restrictive practice.

Sorry, what now? CQC asked the registered manager to investigate allegations of abuse and take appropriate actions, and they did nothing. Leaving people at risk of harm. Meanwhile senior staff are restraining people.

The report goes on to tell us following the inspection SENSE “brought in senior managers from within their wider organisation to undertake a full review of accidents, incidents and concerns” and that relatives had been unaware of the potential risks prior to the inspection.

Staff were also unaware of the risks and associated actions to take in response to residents epilepsy. Three people living in the home with epilepsy had no specific care plans, risks assessments or protocols for staff to follow, related to their epilepsy. Another person’s care plan appeared to suggest staff should just wait and see whether they regained consciousness after a major seizure. This is deathmaking.

There was missing and inaccurate information regarding the management of people’s health needs. For example, 3 people who had a diagnosis of epilepsy did not have any specific care plans, risks assessments or protocols related to their epilepsy. This meant it was not clear the actions staff needed to take in response to any seizures people may have, although staff we spoke with said they would contact emergency services in the event of a person having a seizure.

One person’s care record did inform staff to await consciousness if the person had ‘a major seizure’. There was no further information regarding this instruction, and it contained no date. This is not reflective of current medical guidance, for example the National Institute of Clinical Excellence (NICE) (Epilepsies in Children, Young People and Adults, NICE guideline, Published 27 April 2022).

Medicines weren’t stored safely. Care wasn’t always delivered in line with the Mental Capacity Act and there was evidence of mechanical restraint and physical restraint being delivered, without appropriate safeguards in place.

There was no evidence in people’s care records decisions made about care and treatment considered the involvement of people in their care. Decisions were made for them rather than with the people using the service. We could not find in people’s care records where attempts had been made to adapt communication or to involve advocacy to ensure decisions were in accordance with the Mental Capacity Act 2005. For example, whilst there had been a best interest meeting regarding the use of restraint outside of their assessed needs to carry out an aspect of personal care. There was no evidence that any attempt had been made to engage or communicate with the person to gain their views or consent. During the restraint the records state they ‘initial struggled’, however the restraint continued. Staff did not recognise this as valid communication of not consenting to the intervention continuing.

There were failings in relation to the environment (see report for more). Inspectors also found risks associated with eating, swallowing and choking, that were not mitigated.

The management of people’s nutritional and hydration needs were not always effective. One person had part of their eating and drinking guidelines displayed on the inside of a kitchen cabinet. The guidelines were dated 2016 and were page 3 of 3, pages 1 and 2 were not in the persons records and staff could not tell us what information was missing. Whilst the information told staff the food texture was ‘soft and moist’, there was no information about what the person’s needs were in relation to the thickness of drinks. There was no evidence of input from Speech and Language therapy in the writing of the guidelines and no risk assessment in relation to choking, it was not clear what the choking risks were for this person.

This is almost carbon copy of the evidence we heard at Peter Seaby’s second inquest, of staff not knowing what his SALT plan said, no-one being able to definitively say where it was kept, or whether they had read it. This ambivalence to things that could kill people on a daily basis, is breathtaking.

Another person’s ‘Eating and Drinking Guidelines’ (dated 16 June 2015) stated they were known to eat at a very fast pace and regurgitate food during mealtimes. There was no information or assessment of the likelihood or severity of the risk of choking. We observed staff supporting this person verbally prompt them to slow down when eating their lunch. This issue was not reflected in the screening tool completed by the registered manager 28 March 2023. This inaccuracy meant monitoring was ineffective in identifying and escalating risk.

Staff told us they had raised concerns with the management team previously about the lack of clear guidance around people’s eating and drinking needs in care records but told us nothing had been done to improve the situation.

And we wonder why there’s an apparent “staffing crisis” in social care. When will people start lifting their eyes from the people employed to provide care, to those who are meant to manage and oversee it? As the inspectors state “Staff did not feel supported by the management team”.

Whilst the provider had developed their own ‘Managers’ Eating and Drinking Screen’. This screening tool did not reflect current best practice and national guidance or provide clear guidance about what managers should do when people’s needs changed. One person’s care records stated certain changes in risk should be referred to a Speech and Language Therapist, however other guidance on the screening tool stated a referral was not required in these circumstances. This was confusing and potentially the person at risk of harm if referrals were not made in a timely manner.

We found a screening tool completed by the registered manager 28 March 2023 for 1 person using the service indicated 2 areas of concerns but there was no information about whether this was a change in their needs or what actions were being taken to mitigate any risk.

Then inspectors also observed othering of the highest order. This is what frightens me, when staff are prepared to ignore people’s concerns, in front of inspectors, and just ascribe communication as “behaviour” whatever that means.

During the inspection visit, one person was heard telling staff ‘tummy ache’ as they were about to have their lunch. When we asked staff about this, they told us they believed this was a behaviour. However, when we looked at the care records there was no evidence of any consideration of referring to health professionals to identify any potential causes. There was no action taken to ensure their needs continued to be met.

Such apathy. The well-led section of the report is bullet after bullet of leadership failures.

There were more services rated inadequate in September, you can find a list of them all here. I’m out of steam for now. Need some lunch and some fresh air, but at some point I’ll return and cover the services that were so bad they closed down shortly after.

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