November’s inadequate care

There were a smaller number of reports published in November than previous months, but I’ll highlight the ones that were providing support to autistic and learning disabled people. I’m not covering providers that have since closed down, because I’ll do all of those later.

First up, Ashfield Care Homes Limited in New Milton, Hampshire.

This care home can support up to 10 people but at the time inspectors visited only 6 people were living there. The home was last inspected in May 2021, when it was found to require improvement, and to be in breach of a number of legal requirements.

The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment and good governance. We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well led which contain those requirements.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from requires improvement to inadequate. This is based on the findings at this inspection.

The provider is still in breach of the legal requirements, over two years later. It does beg the question of how well resourced CQC are, if so much time can pass between inspections, when a service is known to be in breach of legal requirements. It almost like legal requirements for certain people don’t count as much.

Inspectors found the following:

Right Support: People were not always 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 this practice. The environment was cramped and not suitable for people who used wheelchairs. Corridors were narrow and we observed 1 person trying to get around a corner and needing help. The dining area was cramped and did not allow sufficient space for the 4 people who used a wheelchair to eat with enough personal space. There was no room for others to eat in the dining area at the same time, had they wished to. The registered manager said they would turn an upstairs bedroom into a lounge/dining room for the person that lived upstairs, along with a second person who was mobile. However, this did not offer meaningful choice and could lead to isolation and exclusion and did not resolve the small, cramped dining area downstairs. In response to our feedback about the limited space available in the dining room, the provider removed the breakfast trolley to increase the space available. In the longer term the provider told us they were planning to extend the current dining space.

Right Care: Some aspects of people’s support were person centered. For example, 1 person was being supported with the aim of them moving into supported living when they were ready. However, we observed some institutionalised and restrictive practice which did not promote people’s independence, dignity, privacy and human rights. For example, 1 person waited around the front entrance hall for much of the morning wanting to go out but was told they would need to wait until the driver got back and then everyone could go out together. Staff told us there was only 1 driver on shift which made it difficult to support people to go out.

One person had their back to the wall with a table in front of their wheelchair. The registered manager told us the person was able to propel themselves backwards or push the table away from them. However, no staff were in the lounge to help the person manoeuver if they got into difficulty which meant there was a risk the person would not be able to move freely. Another person was told to sit down, and staff put their hands on the person’s shoulders to emphasise this without discussing the person’s wish to stand up. The environment was in a poor state of repair with rubbish and disused items left in the garden areas. The home was dirty and unloved which did not respect the fact it was peoples’ home. Shared areas were not very homely or personalised.

Right Culture: Staffing levels did not always enable people to live inclusive and empowered lives. There were not enough staff hours rostered to ensure people received their assessed 1 to 1 support hours. Activities were often shared and based around staff availability rather than personal preferences. Care practice was very mixed depending on people’s abilities. Whilst 1 person was able to live quite independently, others were not. For example, 1 person wanted a coffee at 10.46 am and was told by staff it was nearly 11.00 (coffee time) when they would make one for the person.

We identified concerns with medicines management and administration and staff practice. Staff lacked knowledge of emergency procedures relating to people medicines and health conditions. This put people at
risk of harm.

The provider had systems in place to monitor the quality and safety of the home. However, these were not always effective in identifying shortfalls which put people at risk of harm and/or poor outcomes.

I really struggle with this. How does someone who requires a wheelchair to mobilise, end up living in a home where the corridors are too narrow to effectively move around, and the rooms are too small for people to access? Which commissioner thought that this would be an appropriate place for them? In fact which commissioners, given 4 of the 6 people in the service used wheelchairs?

Let’s dig a bit deeper into the report.

Risks to people’s safety had not always been identified and managed which meant they were at risk of harm. Staff advised 1 person needed to always have a member of staff around due to a health condition, however they also advised this wasn’t always possible. The registered manager had told us on the first day of inspection the person needed someone with them unless they were in bed. They also told us there needed to be a staff member in shared areas whenever the person was there. Their reviewed profile document stated, “I must never be left alone, unless I am in bed”.

We observed multiple periods of time where there were no staff members present in the lounge when the person was there. Staff told us, “It’s a risk [low staffing levels],” and “We manage the best we can, but it can be a concern sometimes.”

The person was also prescribed a blood thinning medicine which meant they were at risk of excessive bleeding if they had an injury. We asked staff what the process was if the person had an unwitnessed seizure or hit their head during a seizure. They were not able to tell us and did not indicate an understanding of what was being asked.

I sort of can’t get my head around this logic. What possible situation could mean someone needs someone with them at all times, but can be left when it suits? Also why are they safe in bed? Perhaps they have narcolepsy, or I suspect more likely they have epilepsy and a bed alarm, but we also know alarms alone do not keep you safe.

Remember Danny Tozer who died in Mencap care? His inquest heard how staff “simulated a seizure” on his epilepsy sensor mat after he was taken to hospital, to check whether it was working. You can read more in Sara’s blog post here.

Also, we heard evidence from a Support Worker at Peter Seaby’s 2nd inquest for how concerned she was by understaffing at The Priory home where she worked, and the evasiveness of management/her seniors when she asked how she was able to provide 1 to 1 care with insufficient staff.

Anyhow, I digress. Clearly this person should have constant support, and clearly the provider is being paid to provide it, and clearly they aren’t, and they admit as much to inspectors. What else?

There were numerous maintenance tasks outstanding which posed a risk of injury to people. For example, a disused cable hanging down and coiled on the floor in the lounge created a trip and potential ligature hazard. We discussed this with the registered manager on the first day of our inspection, but it was still there when we returned on 16 August. Discarded items, including a mattress and empty paint pots, were left around the garden areas and a garden chair partially blocked a wheelchair ramp. An item of furniture was stored under the staircase. This posed a risk to the evacuation route in the event of a fire. This was discussed with the registered manager at our last inspection.

I’m not sure apathy is a strong enough word here. Inspectors, who come from the regulator, who have the power to close you down, visit your service and raise concerns with you about potential trip and ligature hazards on 27 July and 20 days later when they return, it’s still there.

Two years previously an obstacle that posed a risk to people in the event of a fire was discussed with a registered manager. Two years later it is still in the way. Two years.

Medicines were not always managed safely. We found a number of concerns which meant we were not assured people were kept safe from harm of poor practice.

The medicines cabinet was left unlocked, wide open and unattended on at least 4 occasions during our inspection, despite staff having been prompted by inspectors.

Staff and the registered manager told us staff needed permission to administer ‘when required’ or PRN medicines. This meant they would need to contact the on-call manager out of hours. For example, one person’s PRN medicine administration chart directed staff to administer a medicine in a crisis. During our second site visit, conducted in the evening, we attempted to call the on-call manager twice between 8pm and 9pm and received no response. Staff were not clear on who to escalate to and we had to contact another of the provider’s care homes. We were concerned this would mean a delay in a person receiving their medicines if required out of hours, putting them at risk of harm.

Definitely need a stronger word than apathy, are they perhaps demonstrating contempt? An inspector prompts you that medicines should be locked away when unattended and you, what exactly, choose to ignore them?

As for the on-call management. This is such a common scenario too. On this occasion CQC inspectors not being able to contact the on-call manager led to know harm, but how often is that not the case? I’ve heard so many support workers tell coroners that they wouldn’t call an ambulance for an unwell resident without checking with their manager first, not least because there are never enough staff on duty for them to attend hospital and leave other people behind.

Inspectors found that the home was also dirty and staff were not preventing the spread of infection.

The provider had not maintained a clean and safe environment. At our last 2 inspections, we raised concerns about poor cleanliness and peeling surfaces and furniture which created an infection risk. At our inspection in May 2021, we found the provider was in breach of Regulation 12, safe care and treatment, of the Health and Social Care Act (Regulated Activities) Regulations 2014. While some action had been taken, for example replacement of ripped easy chairs and repainting of some surfaces, at this inspection, unsafe and poor infection, prevention and control (IPC) practice remained.

An IPC audit had been carried out on the morning of 27 July 2023, which showed everything had been checked and no concerns were identified. This was not what we found later that morning. A windowsill, banister post and the front door were black with built up dirt. Damage to surfaces in a bedroom and bathroom made them porous which meant they could not be hygienically cleaned. There were hairs and dirt around the base of a hand-rail by a toilet which had not been cleaned. The area around the drain plug in the wet room was black with build-up of wet grime.

We observed staff did not always use personal protective equipment (PPE) when assisting people with personal care. This posed an infection risk.

Staff also demonstrating how pointless audits, checks and balances are if people do not want to see what is right in front of their noses.

During our inspection, we found there were not enough staff to provide person centred support, to meet peoples’ assessed needs and keep them safe. The staff rota showed there were not enough staff to meet people’s support hours as assessed in the provider’s dependency tool. This included 1 to 1 support hours and shared support (core) hours. This meant people did not consistently receive the level of support they required.

For example, a staff member told us on 27 July 2023 there was a lack of drivers, and this was a challenge. The driver on duty had gone out with a person in the home’s transport, and 2 staff members and the registered manager had remained at home to support the other 5 people. We observed people did not receive any meaningful interaction or 1 to 1 support during this time. One person had been waiting in their wheelchair by the front door for much of the morning wanting to go out. A staff member told us everyone would have to wait until the driver came back and they could all go out together in the home’s transport.

This is not a life. A commissioner somewhere is paying for people to have support, that this provider is not providing. The home’s transport is a euphemism for a minibus, as we read later in the report. Not sure how many family homes use minibuses for transport, and fairly sure that being driven around in a minibus with all your housemates is not a meaningful activity.

One person required 1 to 1 support at mealtimes. However, we observed a staff member sitting with the person while eating whilst also supporting another person. They had asked, “Would you like your cereal yet? I am going to be sat here for a while, I am not forcing you but now is a good time as I can sit next to you”. The same staff member told us, “It’s only been possible [to sit with them] because everyone else has finished eating and [the other person] is there so someone is sat with her”. This put the person at risk of not meeting their dietary needs.

That one to one support at mealtimes will be being paid for… whilst the person is subject to coercion, to eat on timetable to suit the staff.

Perhaps the most concerning feature, is that the managers do not know what they don’t know, so there is little hope for improvement. This place is really an institution crammed into a home on an ordinary street, but it’s still an institution, and people are not leading meaningful lives.

We were not assured people were empowered in all areas of their lives. The provider’s audit, dated 6 April 2023, incorrectly confirmed the service was working in line with statutory guidance: ‘Right Support, Right Care, Right Culture.’ This is not what we found during our inspection.

The provider had not considered the statutory guidance ‘Right Support, Right Care, Right Culture,’ in relation to the premises. People had personalised their bedrooms with accessories of their choice, including posters, bedding and curtains. However, there was little evidence to show people had been consulted about their preferences in relation to environmental décor, including consideration of any sensory needs in the shared areas. Following our feedback, the provider sent a maintenance plan which included a plan for consultation with people on redecoration of their bedrooms and shared areas of the home.

A refurbished dining area had 2 small half-moon tables, and the area was cramped when people were in their wheelchairs at mealtimes. There was no room for 2 people, who were mobile, to share in the mealtime experience if they wished to. The registered manager told us as a temporary measure, they would turn an unused bedroom upstairs into a lounge with a dining table for the 2 mobile service users. This meant there would be little choice for them in where they wanted to eat and could lead to feelings of isolation and exclusion and did not resolve the issue of the cramped downstairs dining room.

The shared lounge was functional but not homely. One person sat in their wheelchair in the middle of the room as there was no space for them to sit anywhere else.

There were some institutionalized practices. For example, when a person asked about a coffee at 10.46 a staff member told them it was nearly 11 o’clock, coffee time, then would make one. We saw many instances when people were sat in the lounge with no meaningful activity or staff interaction. Activities were often based on staff availability and were often shared experiences, rather than individual preferences, such as everyone going to the pub for lunch. The registered manager told us everyone needed support to go out and this could be shared.

Despite all the low level failings in plain sight contained in this report, I think the point that broke me the most was the last bullet. How many people, in their own homes, have visit from pet therapists, rather than owning a pet? For all the talk of care homes being people’s own homes, and having rooms with accessorise people choose, if you want a pet, no no, you can have a visit from a pet therapist once in a blue moon.

A pet therapist attended the home regularly and brought small animals such as rabbits and guinea pigs, which they told us everyone loved. We saw there was a good rapport between them and the manager.

Next up Suncare Recovery Ltd, Two Rivers Care Home in Finchley. Where do they get the names from? I can tell you there are two rivers in Finchley, well strictly speaking they’re brooks, so smaller than rivers, and one is a good half hour walk away, the other 20 minutes, so I think this is stretching it. I’m also not sure what the autistic and learning disabled people are meant to be recovering from? The non-care they’re subjected to by Suncare Recovery perhaps? Inadequate on every domain assessed.

First up, this service is jointly registered, so it is not just a care home.

This service is jointly registered as a residential care home and a domiciliary care service, which provides care to people living in supported living services. The residential part of the service is called Two Rivers and is registered to provide personal care and accommodation to 8 people. The care home is a house with a garden and access to the high street. The supported living service supports 15 people in three shared houses. In each shared house people share the kitchen, lounge, and some bathrooms. There is sleep in staff and an awake staff who monitors the CCTV footage in people’s bedrooms and lounges from the residential part of the service. The services purposely supports Asian women who have learning disabilities, physical disabilities, and who are autistic.

The inspection happened following reports of an incident where a person using the service “sustained a serious injury”. The report tells us that incident is subject to further investigation by CQC as to whether any regulatory action should be taken, so this inspection did not examine that incident itself.

What did inspectors find?

Breaches of legal requirements in relation to:

  • people’s safety
  • management’s response to safeguarding concerns
  • restrictive practices and the application of the mental capacity act
  • person-centred care
  • promoting privacy and dignity, and
  • failures in the leadership of the service at this inspection.

The service had been inspected 5 months earlier, in March 2023, and rated good. That inspection took place after concerns were raised about safety of care, and a targeted inspection looking at safety and leadership found concerns relating to staff recruitment and quality assurance, but found no evidence that people were at risk from poor care.

So there is either considerable deterioration in five months, or maybe there are questions to be asked about how thorough the previous inspection had been? Or both. It is now rated inadequate and in special measures.

Right Support: People at times did not receive safe care. Risk assessments and care plans did not explore and explain fully what people’s needs were and how they should be supported by staff. When people moved to the service this was not completed in a planned, safe, and thoughtful way. Staff were not well trained to understand people’s needs outside of their personal care needs and to know when they needed to advocate for people. There was a lot of surveillance and restrictions in place which could undermine people’s rights and choices. People saw health professionals frequently to support with their health needs. People were not supported to have maximum choice and control of their lives and managers, the provider 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: Work had not been completed to look at people’s life goals, their interests and what they found fun as individuals. No plans were made to try and make these goals and what people enjoyed happening. Some staff were thoughtless towards some people, and they did not promote the home as people’s own space. People had blanket routines such as what they ate, what they did, and when they went to bed rather than look at what individuals wanted to do and to make these routines happen. Some staff were thoughtful towards people, but people were not always being treated as adults. People ate nutritional food cooked by staff which people said they liked. But routines meant people could spend a long time in bed without access to drinks and on their own. People’s religious cultural needs were promoted at the service.

Right Culture: The leaders of the home had not created a culture which established a safe and person-centred experience for people to live in. The provider was not effectively assessing the quality of the care at the home. They were not looking at what people’s experiences were like and considering what else could be done to reduce restrictions and make life more enjoyable.

The provider and managers had made some improvement to processes to promote people’s safety and had started looking at staff skills and support following our feedback. But there was a lot to do, and more time will be needed to improve the service. Based on our review of safe, effective, caring, responsive and well led the service was not able to demonstrate they were meeting the underpinning principles of right support, right care, right culture (RSRCRC).

So what was it like for the women who lived there? Let’s look a bit deeper. I’m thinking it would feel like you were in an institution, dressed up as a home to the outside world.

A person had experienced degrading treatment. They had also been put at risk and experienced an injury.

We found examples of institutionalised practice, such as blanket routines, surveillance, and information displayed to benefit staff rather than people.

Personal information was displayed on laminated posters in people’s bedrooms; this was for the benefit for staff not the person themselves.

Faecal matter was found on a person’s made bed.

Some people’s incontinence products had been taken out of their packaging, sometimes exposed close to open windows.

A person was treated in a degrading way by a member of staff. Other staff did not challenge this issue.

Staff were seen to roughly wipe people’s mouths after mealtimes in communal spaces, staff did not explain they were going to do this to people. Toilet times were announced by some staff in front of other staff and people.

There were blanket routines such as times to go to bed and meal choices. Routine group events as opposed to individual events, only took place.

When we saw poor staff practice we did not believe this was the result of staff being intentionally unkind, but a result of the lack of training and support staff had received from managers, registered manager and the provider.

Daily routines were institutionalised so everyone ate at the same time and went to bed at the same or similar times. When we visited the care home one evening everyone was in bed by 19:30 most were awake. No evening events or social time was being offered.

Care plans did not show people were being involved in their care decisions or efforts were being made to do what the person wanted to do.

The home and supported living service was institutionalised in many ways. In how it managed risks, promoted people’s freedoms, and created opportunities for people to find things they enjoyed and to have fun.

When things went wrong, inspectors found no evidence that the provider had followed appropriate systems or legal requirements.

There were poor systems and poor safeguarding knowledge by the provider. Safe systems to respond to a local authority safeguarding investigation were not in place.

The provider had not fulfilled their duty of candour when something went very wrong. 2 people experienced inadequate care with 1 experiencing an injury.

People were not safe when they were eating.

A person who was at risk of choking and who had been assessed to have a specialist diet by a health professional was being supported to eat at pace and in an unsafe way on two occasions by staff.

Staff were not knowledgeable about what some people’s specialists’ diets were, who were at risk of choking. They did not have access to people’s current guidelines from food specialists.

Some relatives were concerned people could be hungry and thirsty in the evening as dinner was at around 17:00 and people went to bed early. We also raised this with the registered manager and provider.

People were not safe more generally, with no meaningful risk assessments in place to protect people from harm and promote safe practices.

Risk assessments did not explore all the risks which people faced. They were often generic and not personal to the person. Risk assessments also lacked detail and staff did not have access to effective care plans to support their

When people returned from long hospital stays or moved from the residential part of the home to the supported living service, full risk assessments and care plans were not completed.

There was no system to follow up on incidents and accidents. There were no checks when incidents happened staff had responded appropriately.

When people’s care plans instructed staff to give people their medicines at the correct times these ‘correct times’ had not been obtained and clarified. We completed a medicine count for 4 people’s medicines, most medicines remaining tallied with what had been given, but 1 person’s medicines did not, and this could not be explained.

There were not enough staff on duty.

Staffing levels were not sufficient to support people at night who were awake or wanted to be awake.

The provider had changed the presence of awake staff in the home without considering how some aspects of safety monitoring at night would take place in the supported living services. There was insufficient staff deployed to ensure people needs were met.

There were no systems in place to help staff learn from mistakes and do better.

Due to a lack of effective processes and leadership at the service, there was not the opportunity to learn from mistakes.

We observed poor staff practices in relation to treating people in a person centred and thoughtful way, supporting people to access their home, use the stairs safely, eat safely and engage with people at these times safely. These were all indicators of poor staff training and support.

The manager and provider were breaking the law and were not compliant with the Mental Capacity Act.

The registered manager and provider were not compliant with the MCA. There were examples of restrictions which had not been reviewed effectively to see if these were the least restrictive option.

Some people did not have access to their clothes. A person had a tray table attached to their wheelchair which a professional had arranged, no one had considered this was a restriction. Staff had also kept the tray table attached well after lunch had finished.

CCTV cameras were in operation 24 hours daily, with no consideration during personal care times, when people were amongst staff in the lounges, and when some people did not need this level of monitoring.

People who were funded to receive one to one care were receiving this care in an overly restrictive way. People did not have access to parts of their home when they wanted to.

Some people’s relatives were making decisions on their relative’s behalf without the legal authority to do so. Deputy managers understanding of power of attorney and court of protection was not sufficient to promote people’s rights regarding this.

When best interest decisions were made, correct best interest processes were not being followed.

There were missed opportunities to advocate for some people’s rights at times and consider other expert support and advice.

The people using the service appear to be invisible, there were no attempts to get to know their hopes or dreams, or even what they liked to do. Activities were not as advertised.

Staff, deputy managers, the registered manager, and the provider did not try and identify and promote what people liked to do. People did not have personalised plans which explored their interests and made goals to try and achieve these.

When some people expressed a particular interest, staff and managers did not take advantage of this opportunity to help people fulfil these and consider how these interests could be achieved.

Planned events were walks to the local park, bus rides sometimes to no destination or to go to Brent Cross, and swimming which was seasonal. But few other options were provided. Events were group events not individual ones. We were told this was because of the staffing levels.

When ‘activities’ were planned in the home these were described as something they were not. We were told one afternoon an activity of head massages and feet massages was happening. But this isn’t what happened. People had their feet creamed with their prescribed creams and staff re-braided people’s hair. Staff were not trained to provide the activities offered.

Right Support, Right Care, Right Culture meant nothing to the registered manager and provider. The regulator’s guidance on how they should be delivering care.

The registered manager and provider did not know about RSRCRC and they had not implemented these values into the home and supported living services.

They had no effective quality monitoring systems to test the quality of the care provided. The audit they did complete was irregular and limited in scope, which captured no evidence to show how they had conducted their audit.

Nor had they questioned some aspects of staff practice, when supporting people with aspects of their personal care, which had become routine, even when it could put people at risk of harm.

It is hard to understand what the registered manager and provider were doing, because they weren’t following guidance, or the law. They weren’t ensuring their service was not an institution. They were not providing adequate training or support to staff. They were not conducting risk assessments or following safeguarding procedures.

The registered manager and provider had not ensured staff were well trained and supported to contribute to people having a positive person-centred experience.

The registered manager and provider had not been open with their internal reporting and investigation when a person experienced harm.

The registered manager had not followed the provider’s own policy when accessing CCTV footage remotely and did so in a way which made staff feel overly observed.

All of these factors created a closed culture at the service.

CQC have issued warning notices to the provider. Another case of watch and wait.

We issued a warning notice highlighting this breach to the provider and warning if they are not compliant at the next inspection we may take further enforcement action. We issued a date the provider must be compliant by.

Finally for today, another flurry of red dots. Maple Health UK Ltd, Maple House in Colchester.

Nothing screams someone’s own home, not an institution, more than a great big colourful sign at the entrance to the close advertising your care provider. Oh wait.

Maple House is at 1 Amber Court, Maple Lodge is at 2 Amber Court, also rated inadequate in December 2023, Maple Manor at 3 Amber Court rated requires improvement in December 2023, Maple View is at 4 Amber Court also rated inadequate in December 2023, and Maple Cottage is at 5 Amber Court, rated requires improvement in December 2023.

According to Zoopla no property at Amber Court Colchester has ever been sold and there are only 5 bungalows at the address, all filled with learning disabled and autistic people. Some might suggest this is nothing more than an institution, in plain sight. This is not community living, if all your neighbours are also receiving care and support from the same provider.

The inspection at Maple House took place because of concerns that CQC received about “the unsafe use of physical restraint”. This is what inspectors found:

Right Support: The model of care and setting did not maximise people’s choice, control, and independence. 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 not adequately trained and did not always have the skills, knowledge and competence required. This included the routine and disproportionate use of non-recognised and unsafe physical restraint.

Right Care: Care was not consistently person-centred, or always provided in a way which promotes people’s dignity, privacy, and human rights. People were at avoidable risk of harm, through poor management of incidents and safeguarding concerns. Staff did not recognise or act appropriately on poor practice. There were safety issues relating to medicines management, fire, and infection prevention control. Suitable risk assessments were not always in place, and some care records were out of date.

Right Culture: The ethos, values, attitudes and behaviours of leaders and care staff did not ensure people using services lead confident, inclusive, and empowered lives. Governance and oversight measures were either not in place or ineffective to ensure the safety and quality of the service. There were multiple indicators of a closed staff culture, which included leaders, placing people at the ongoing risk of receiving poor care.

Maple House had last been inspected in August 2018, when it was rated good. I dread to think how long people had endured this non-care.

Inspectors found breaches in relation to person-centred care, dignity and respect, the need for consent, safe care and treatment, safeguarding, governance, staffing and recruitment.

This place sounds horrendous.

The provider had failed to keep people safe from the risk of avoidable harm, and staff did not understand how to protect people from abuse. Multiple incident reports showed staff using ad hoc, disproportionate and ‘non-recognised’ restraint without legal authority. This was contrary to national best practice guidance and the provider’s safeguarding policy. Staff had either not received training in physical restraint or had last received the training in 2019. There was no restraint policy in place, and no detailed risk assessments to guide staff. The service did not always record the use of restrictions on people’s freedom and managers did not review the use of restrictions to look for ways to reduce them.

There were indicators of a poor and closed staff culture, with allegations of bullying, violence, and sexual misconduct or inappropriate personal relationships amongst some staff, contrary to the provider’s own conflict of interest policy. This had the potential to directly impact people using the service. We reviewed 3 people’s care plans which showed they all had sexual safety risk factors. Leaders had not acted to identify and mitigate the impact of inappropriate staff conduct in front of people, including where this was a known trigger for extreme anxiety and distress. This placed people at significant risk of harm.

There was no effective investigation of incidents and safeguarding matters, and no action plans or analysis of themes and trends. This meant there were no lessons learned to reduce the risk of reoccurrence, including no credible vision for proactive restraint reduction, and poor practice continued. There was a blame culture at leadership level, placing the responsibility for the service’s normalised unsafe practices on outside stakeholders. When safeguarding referrals were made to the local authority, the forms were poorly completed and lacked detail on the severity of the incidents they related to.

CQC took swift action on this.

We raised our urgent concerns with the provider relating to the unsafe use of physical restraint. We also reported this to the police, and to the local authority safeguarding team.

Not only were people at risk of multiple forms of abuse, they also were unsafe in other areas.

Leaders failed to assess or act on known risks to people’s safety and welfare. Risk assessments in relation to areas such as physical restraint, choking and fire safety were poor or not in place.

Personal Emergency Evacuation Plan (‘PEEPs’) lacked sufficient detail on how to support people to safely leave the building in the event of a fire, including how to reduce distress or the potential impact of sedative medicines on people.

A person at risk of choking who had been referred to the Speech and Language Therapy team had no choking risk assessment in place.

Staff did not consistently manage the safety of the living environment and equipment in it through checks and action to minimise risk. The provider’s own audits had identified multiple fire doors which were not working correctly since April 2023, but no action had been taken to repair them. This placed people at an increased potential risk of fire and smoke spreading throughout the building in an emergency, including those with reduced mobility.

Systems and processes to administer medicines safely were not always clearly in place or followed.

It will come as no surprise that people were at risk of being subject to excessive medication too.

Another person had their PRN (‘as required’) medicine dose for supporting them when expressing distress changed by the registered manager, before consulting a healthcare prescriber. This did not ensure people’s behaviour was not controlled by excessive and inappropriate use of medicines contrary to the principles of STOMP (stopping over-medication of people with a learning disability, autism or both).

The place was generally grotty in places too.

The service did not consistently employ effective infection, prevention and control measures to keep people safe. Whilst some areas of the service were clean and hygienic, others were not. We identified rust to fittings and fixtures in a shared bathroom, as well as a worn toilet brush, mould to bath sealant and a cracked tile. Sofa upholstery had a rip in it, which meant it could not be effectively cleaned. We also found an inflatable plastic pool with organic matter and dirt in it. Stagnant water can act as a reservoir for harmful bacteria, placing people at risk of illness.

Seems like there were sufficient staffing if people wanted to live a life trapped in their ‘home’ but not if they wanted to leave it and do anything.

There were sufficient staff numbers deployed to support people within Maple House, but not to ensure good access to leisure activities outside of the service.

It will come as no surprise that the care and support provided was not meeting even the basics. Care plans were variable, but that didn’t really have much impact because some staff told inspectors they didn’t read them anyway.

The provider failed to ensure people’s care and support reflected current evidence-based guidance, standards and practice, and care was not always provided to meet people’s assessed needs. Care plans were of variable quality. Whilst some parts of people’s care records had a good level of detail and personalisation, other parts were of poor quality, out-of-date, or contrary to best practice. Some staff told us they had not read care plans or were not sure of people’s needs.

People were not supported by staff who had received relevant and good quality training in evidence based practice in all areas, or fully understood the principles of training they did receive.

I’m not sure that I feel better knowing these staff will be trained in physical restraint, but I’m not surprised it hadn’t happened before due to the provider not wanting to eat into their profits. The registered manager doesn’t sound fit for the job.

Staff were not trained or confident to carry out physical restraint, and the skill mix for doing so was incorrect. One staff member said, “Because of staff confidence, difference in height, we have quite a few female team members. It’s difficult.” This had led to staff being injured on occasions. Teams did not hold debriefing meetings or reflect on their practice to consider improvements in care following incidents.

Staff did not receive support in the form of good quality supervision, appraisal, and recognition of good practice. The registered manager did not always give honest feedback on staff performance to support them to improve. For example, 1 staff member who had shown significantly poor practice during an incident received an appraisal 1 month later stating they were ‘good’ or ‘excellent’ in all areas. When allegations of a safeguarding nature were made against staff, the registered manager did not act promptly to suspend them whilst investigating concerns.

Following our urgent concerns, the registered manager took action to book physical restraint training for staff. However, this had not been independently acted on or prioritised despite being a known risk. The registered manager confirmed to inspectors the decision not to source specific training prior to our feedback was for financial reasons.

Again, it will shock no-one that this service was not operating in line with the law and the Mental Capacity Act.

Staff did not consistently demonstrate best practice for assessing mental capacity, supporting decision making and best interest decision-making. Some decisions were made contrary to people’s best interests. For example, the registered manager made a best interests decision for a person to be restrained by staff using techniques staff were not trained in.

There was no oversight system for DoLS, and we found DoLS application outcomes had not been notified to the CQC as required by law. We found conditions relating to DoLS were not always met, including a condition explicitly stating non-recognised restraint methods must not be used.

It also makes me wonder what was known elsewhere that a DOLS condition was explicitly added stating non-recognised restraint must not be used… why would that be added unless someone somewhere already had concerns? How long were these people subjected to this?

Ahhh yes, and then we get to the meat of it, regardless of how staff spoke about people in front of inspectors, the care plans reveal their true thoughts. Surely there is no safe way these people should be allowed to provide restraint?

The provider failed to put in place systems, processes, and resources to enable staff to provide a caring service. This included poor training, staff deployment and ineffective supervision, leaving staff to provide intuitive care. There was a lack of provider oversight and action was not taken to address known risks and shortfalls in the service, including multiple closed culture warning signs. This meant staff did not respect and promote people’s privacy, dignity, and autonomy at all times.

Staff did not ensure people were protected from exposure to any environmental factors they would find stressful. People were at risk of degrading and uncompassionate treatment when distressed and at risk of self-harm. Staff had not escalated these very serious concerns to external authorities, through whistleblowing or safeguarding channels. There was limited understanding or evidence of emotional support and reassurance for people following incidents or restraint.

Whilst staff spoke warmly about the people they supported, care plan records contained demeaning and disrespectful language to describe people, which could impact on their confidence, well-being, and self esteem. This included stating how “[Person] will try to play staff off against one another to get [their] own way” and how another person would, “…manipulate a situation to get what [person] wants.” People were described as “very argumentative”, “demanding” and having “violent and aggressive behaviours” such as “lashing out at staff.”

Imagine being stuck in this place. No activities outside the home. Being restrained, in your own home. No kindness, no ambition, no understanding. No life.

Staff did not always speak knowledgeably about tailoring the level of support to individual’s needs and people’s changing needs were not always responded to in a person-centred way. We spoke with 1 staff member who was not aware a person they were supporting was autistic. This meant they would not be able to provide personalised support. Some care records made inappropriate blanket statements which did not reflect best practice models of care, such as stating an autistic person, ‘lacked empathy towards others.’

Changes to routines and preferred leisure activities were not always planned or well managed, including the social and emotional impact of this on people. Whilst some people enjoyed meaningful leisure time, others did not have choice and control, were subject to disproportionate restriction and excluded from having the best possible quality of life. One staff member said, “We do the best we can and have been calling out for help.”

The failings in leadership and management were plentiful. It appears to be all about profit and people, but not the people using the service, the staff delivering it.

Management and staff did not put people’s needs and wishes at the heart of everything they did, including a failure to respond to known risks. Many decisions were directly to benefit staff or for financial reasons, and did not consider people’s preferences, needs or best interests. This included the failure to address deficits in physical restraint training, or to replace vital safety equipment such as fire door mechanisms. When the provider did not promptly receive funding from 1 commissioning authority, they stated they would withdraw safe staffing of a person’s care with little notice in response.

Staff did not feel able to raise concerns with managers without fear of what might happen as a result. We saw comments from staff who stated when they had raised concerns they had been removed from the rota. The registered manager was aware of the formation of staff cliques. This was a significant closed culture risk, reducing the ability of staff to speak up safely. Managers did not set a culture that valued reflection, learning and improvement.

The service was not being provided in a way which is compliant with the CQC’s Right Support, Right Care, Right Culture guidance, or other national best practice guidelines to meet people’s needs in this type of specialist setting.

The provider failed to understand their legal responsibility to keep people safe from the risk of harm and did not take accountability and apologise when things went wrong, instead blaming other stakeholders. The registered manager was unable to confirm a duty of candour policy was in place for the service and was unable to meet their duty of candour responsibilities as some incidents were not being identified. This meant they could not be acted upon openly and transparently.

And, finally, a case of copy and paste care, plans lifted from another provider elsewhere. Followed by issues identified 5 years previously, still being ignored.

Policies and plans were not always tailored to the service. For example, the business continuity plan referred to another service and the risk of isolation from the mainland caused by high tide which was not relevant at Maple House. This placed people at risk in the event of an emergency, as there was insufficient guidance for staff.

Improvements from issues identified at previous inspections were still ongoing. For example, we found gaps in records of water temperatures at our 2018 inspection. At this inspection there were none recorded for the last 3 months.

Basic regulatory requirements were not met, such as ensuring statutory notifications were sent to the CQC for police incidents, DoLS application outcomes, serious injuries, and safeguarding matters. This is a legal requirement to ensure the CQC has oversight of any risks at the service. The provider had also failed to display its CQC rating on the company website.

When I get around to December I’ll report on two more of the bungalows in this “complex of residential care homes based in Colchester, Essex” as they describe it on their website.

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