KEPA Care Solutions Limited

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We found two breaches of the legal regulations in relation to good governance and notification of other incidents. The oversight of the service was poor and ineffective. Audits completed by the registered manager and senior staff failed to identify the serious and widespread concerns identified within this assessment. There was a closed culture at the service which the registered manager and senior staff failed to identify and improve. The registered manager and senior staff did not have the knowledge on how best to support people with a learning disability, and autistic people. Key guidance and legislation in relation to supporting people with a learning disability, and autistic people was not followed. The registered manager and senior staff missed opportunities to learn from incidents and accidents.

This service scored 32 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Governance, management and sustainability during this assessment. The score for this quality statement is based on the previous rating for Well-led.

While the people we spoke to expressed that they were generally happy with their care, our assessment found care did not meet the expected standards. People had trusted the provider and registered manager to share important information about their care with partners, to ensure learning and improvements which would lead to better outcomes for people. This had not happened. Because of this, people’s rights had not been upheld and, in some cases, people had been harmed. For example, there were multiple occasions when one person spat at another, and multiple instances when one person targeted another person. The registered manager told us they did not report incidents of abuse, because they knew the person did not intend to cause the other person harm. The registered manager failed to consider how this would impact on the person experiencing abuse.

While staff we spoke with, including the registered manager told us they worked well with key partners, we identified this did not always occur. Staff and the registered manager did not work with partners in a collaborative way to share concerns about the risks to people or incidents that had occurred. People were placed at significant risk because the registered manager failed to be open and transparent with partners about significant incidents which happened between people where harm had occurred. The registered manager had failed to be open and honest with us and with key partners, or to share key information about the service people received, and important information about people’s safety. The failure to work collaboratively with partners had a detrimental impact on people’s safety and outcomes.

Social care professional partners have worked alongside CQC during this assessment. They are reviewing current care packages due to concerns about people’s safety. Partners told us they had not been informed of serious safety concerns regarding the people they commissioned, and they had been concerned to learn of incidents of restraint and unsafe practices.

There were inadequate processes in place to ensure seamless partnership working. The provider and registered manager had not been open or transparent with partners about people being harmed, unlawful restraint, or that other people were receiving a day service in people’s homes. The registered manager had failed to establish robust processes for sharing information with partners when significant events had occurred and people had been harmed. Some people had been significantly harmed both physically and psychologically but the registered manager had not shared these concerns with partners. The absence of effective processes meant that people were not involved in their care, and partners were not involved in meaningful engagement with the provider to explore learning and improvement.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.