About the service S E L F Limited - 14 Park View is a care home and provides accommodation and support for up to nine people living with a learning disability. There were nine people living at the service when we visited.
People’s experience of using this service and what we found
Risks to people were not always safely managed, monitored or assessed. The service did not have effective systems to protect people from the risk of financial abuse. Covid-19 protocols were not always followed, and the service did not have effective systems to prevent and control the spread of infections.
We found restrictions had been placed on people including holding people’s cash cards, allocated time slots for smoking and vaping and fixed timings for mealtimes and administration of medicines. The provider took immediate action to support people’s fundamental human rights in line with legislation when we brought this to their attention.
Quality assurance systems were not effective, lacked detail and did not include all aspects of the service. The issues we found during the inspection had not been identified. The provider had not maintained an oversight of the service, which facilitated a poor culture and allowed poor and unlawful practices to be established and embedded.
The service did not ensure enough staff were deployed to meet people’s needs. Staffing rotas did not always reflect the number of staff on duty and the provider’s expected staffing levels were not achieved.
During our inspection people did not have access to heating and hot water. Following the inspection, the provider confirmed the heating system had been replaced. Maintenance records were incomplete; therefore we were unable to establish how long this problem had been going on.
People’s confidential records were not always accurate and complete and were not held securely.
A training programme was in place. Staff received supervisions and appraisals. However, the majority of staff told us that they were not free to discuss issues at their supervisions as it resulted in a negative impact on them or the rest of the staff team.
Medicines were managed safely. People were referred to health professionals when required.
People gave mixed feedback about the service. Some people told us they were happy whilst others expressed their dissatisfaction about the restrictions placed upon them.
Relatives and social professionals we spoke with were positive about the service and told us people were happy and settled.
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
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 granted. Right Support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.
Based on our review of the key questions of safe, effective and well-led the service was not able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture.
Right support: Restrictive, controlling practices had been adopted within the service. Peoples’ choices had been removed in certain aspects of their lives.
Right care: People did not receive person-centred care and support and the service did not promote people’s dignity, and human rights.
Right culture: Attitudes and behaviours of the management team did not ensure people using services lead confident, inclusive and empowered lives.
Care staff were compassionate about ensuring people lived full lives. They recognised the issues at the service and repeatedly raised concerns with the management team.
The provider is conducting a full investigation into the failings and has put actions in place to address restrictions immediately.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was good (published 20 May 2019).
Why we inspected
The inspection was prompted in part due to concerns received about the safety of people using the service, staffing levels and management of the service. A decision was made for us to inspect and examine those risks.
An initial inspection took place on 2 September 2021 to establish that people were safe. We inspected and found there was a concern with staffing levels and the management of the service, so we widened the scope of the inspection to become a focused inspection which included the key questions of safe, effective and well-led.
This report only covers our findings in relation to the key questions safe, effective and well-led as we were mindful of the impact and added pressures of COVID-19 pandemic on the service.
We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively
The overall rating for the service has changed from good to inadequate. This is based on the findings at this inspection.
We have found evidence that the provider needs to make improvement. Please see the safe, effective and well-led sections of this full report.
You can see what action we have asked the provider to take at the end of this full report.
Following the inspection, the provider has taken action to mitigate the risks. The provider was receptive to our feedback and has implemented new systems and procedures in response.
Enforcement
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service.
We have identified breaches in relation to safe care and treatment, safeguarding, dignity and respect, staffing and good governance at this inspection.
Please see the action we have told the provider to take at the end of this report.
Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.
Follow up
We have arranged to meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.
If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.
For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.