Archived: Cranmore

Updated 29 July 2021

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.

Inspection team

The inspection was carried out by two inspectors.

Service and service type

Cranmore is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

This inspection was unannounced.

What we did before inspection

We reviewed information we had received about the service since the last inspection. We sought feedback

from the local authority and professionals who work with the service. We did not ask the provider to

complete a provider information return. This is information providers are required to send us with key

information about their service, what they do well, and improvements they plan to make. This information

helps support our inspections. We used all of this information to plan our inspection.

During the inspection

We spoke with three people who used the service about their experience of the care provided. We spoke with six members of staff including two deputy managers the provider and care staff.

and two care workers.

We reviewed a range of records. This included three people's care records and multiple incident reports.

After the inspection

We reviewed incident records and spoke with the director and service commissioners about our concerns.

Updated 29 July 2021

About the service

Cranmore is a residential care home providing personal care to six people with learning disabilities, autism and complex needs at the time of the inspection. The service can support up to six people in one building.

People’s experience of using this service and what we found

People told us that they had been hit, and their hair pulled by a person living at the service, and that staff took no to very little action to prevent it. Staff we spoke with lacked the understanding that people would be upset and hurt by this, and failed to report it as abuse. Numerous incidents between people had been logged inconsistently and not reported to the local authority safeguarding team.

Incidents were not consistency logged and there was no oversight or management of incidents. As a result incidents re-occurred and people were harmed. Care plans and risk assessments were not updated following incidents and there was no mitigation put in place to avoid the incident re-occurring.

The culture of the service was poor. Staff spoke about and to people in a derogatory way; for example, calling them ‘silly’ and saying people ‘threw paddies’. People had been ‘told to go to their rooms’ during incidents. People were not supported in a person-centred way in line with positive behaviour support. People’s rights and dignity were not upheld.

People were unlawfully physically restrained by staff who had been trained but their competency not assessed to ensure they were using the correct techniques. The staff who trained the team on how to restrain people had not had recent training. The methods of restraint used described to us could cause people pain.

Staff lacked the skills, knowledge and guidance to support people. Staff were not trained in positive behaviour support, and punitive practices such as not allowing people to get magazines due to behaviours were used.

There was a lack of infection control measures placing people at significant risk from covid-19. Days before our inspection, staff started to wear face masks and told us they had not previously due to people’s distress with PPE (personal protective equipment). People were observed not to be distressed by the PPE worn, and when we asked staff about this, they told us people could struggle to hear when staff used PPE. The service had a covid-19 outbreak in December 2020 and every person tested positive for covid-19.

There was no oversight or governance in place. The registered manager and provider failed to complete any audits of the service and failed to identify the significant concerns we identified during our inspection. The registered manager and provider failed to meet their regulatory requirement to notify us of safeguarding incidents.

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.

This service was not able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture. People had unnecessary restrictions placed on them, such as not having access to toilet paper and being locked out of the kitchen. Staff lacked the knowledge and skill to support people in a person-centred way and lacked understanding on learning disabilities including autism and how people may present themselves. This had a negative impact on people’s lives and infringed on their human rights.

Right support:

• Model of care and setting did not maximise people’s choice, control and independence

Right care:

• Care was not person-centred and did not promotes people’s dignity, privacy and human rights

Right culture:

• Ethos, values, attitudes and behaviours of leaders and care staff did not ensure people using services lead confident, inclusive and empowered lives

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 15 November 2017.)

Why we inspected

We received concerns in relation to the management of behaviours, the competency of staff and the risk management of the service. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. We received concerns relating to mental capacity, and the environment, and therefore we inspected this part of effective only.

We reviewed the information we held about the service. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

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 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.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Cranmore on our website at www.cqc.org.uk.

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 discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to dignity and respect, need for consent, safe care and treatment, safeguarding service users from abuse and improper treatment, premises and equipment, good governance, staffing and notification of other events at this inspection.

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 will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and 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.

Special Measures:

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.