Archived: Mendip House

Updated 6 August 2016

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

We received serious concerns in relation to this service in May 2016. As a result we inspected urgently on 12 May 2016. This was unannounced and carried out by two inspectors. Following this inspection visit we liaised with the provider, the police and the local authority safeguarding team. We then carried out further unannounced inspection visits on 14, 15 and 17 June 2016. These were also carried out by two inspectors. During our inspection we spoke with eight members of staff, the acting manager, the provider’s area manager and the human resources manager. We met each person who lived at the home and observed staff interacting and supporting people in communal areas.

Following our visits to the home we spoke with local service operations manager (who oversee the provider’s homes) on 29 June 2016 as they were on leave when we visited the home earlier in June. We spoke with four relatives and with staff from the local authorities who pay for people to live at the home between 4 and 8 July 2016. We continue to meet and liaise with the police and the local authority safeguarding team.

Before our inspection we reviewed all of the information we held about the home. We reviewed information we had received from the provider and other agencies, such as the police and the local authority safeguarding team. We looked at previous inspection reports and notifications we had received. A notification is information about important events which the provider is required to send us by law.

Updated 6 August 2016

Mendip House is a large detached bungalow situated in the extensive grounds of Somerset Court. The home accommodates six people who have autism and complex support needs. Five people live in the main part of the home; one person lives in a self-contained annexe. People living at Mendip House can access all other facilities on the Somerset Court site which include various day services.

A registered manager was responsible for the service, although they were not currently working at the home. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We received serious concerns in relation to this service in May 2016. As a result we inspected urgently on 12 May 2016. This was unannounced and carried out by two inspectors. Following this inspection visit we liaised with the provider, the police and the local authority safeguarding team. We then carried out further unannounced inspection visits on 14, 15 and 17 June 2016. These were also carried out by two inspectors.

People had not been kept safe. A damaging culture had been allowed to develop within the staff team which had adversely affected people’s lives. Staff had not ensured people’s safety; this had been compromised for some time. Risks to people were not properly assessed, reviewed or managed. Staff had not reported concerns about people’s welfare and safety when they had them.

Some areas of medicines management were not safe. Staff recruitment was not managed safely. Accidents and incidents were not always recorded or followed up to ensure people’s safety or improve their care. Health and safety checks on the home were not carried out which put people at risk.

Current staff were kind and caring but people had not been treated with kindness and compassion previously. People appeared relaxed in the company of current staff on duty. Staff knew the people they were supporting. Staffing was adequate to ensure the continuity of people’s service. Experienced staff from some of the provider’s other services on the Somerset Court site were working in the home to provide cover for the staff who were not currently working. There were permanent staff on each shift.

People’s health care support was poor as health care records were either missing or poorly recorded. People’s health plans did not reflect their current needs. People’s legal rights in relation to decision making and restrictions on their liberty were not upheld.

People did not have a choice of nutritious meals and drinks. Some people’s diets were very poor placing them at risk of malnutrition.

Staff training was not put into practice; some training was out of date. Staff were not supervised regularly and concerns raised in supervisions were not acted upon. Poor staff practice was not addressed and improved.

Some people did not have any formal system to communicate their wishes or feelings. People were therefore unable, and had not been supported to express their views about life in the home. Staff had not raised concerns or complaints on people’s behalf despite the culture prevalent within the home adversely affecting them. Concerns and complaints had not been listened to or responded to. Staff reported a failure to act on concerns they raised which led to them not reporting them any longer.

People did not receive personalised care which was responsive to their needs. Care planning was confusing and out of date. Plans were not reviewed and did not reflect people’s current needs. Some records could not be located during the inspection; there was evidence these records had never been completed.

The home had been extremely poorly managed. There had been a chaotic approach to management systems, structures and record keeping. The provider’s governance and auditing of the service had been weak and ineffective. There had been a lack of action when the home failed to improve in identified areas. The damaging staff culture was known about and discussed both within the home and by the senior management team but appropriate action was not taken.

There had been a failure to operate the home in an open and transparent way or in accordance with the law. Significant events which adversely affected people’s safety and welfare had not been reported to either the CQC of other authorities such as the police or the local authority safeguarding team. This had severely compromised people’s welfare and safety.

We found multiple breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and one breach of The Care Quality Commission (Registration) Regulations 2009.

The overall rating for this service is 'Inadequate' and the service is therefore in 'Special measures'.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their 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.