Archived: Jabulani

Updated 4 June 2020

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

This inspection was carried out by two inspectors and a learning disability nurse specialist advisor.

Service and service type

Jabulani 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. The manager had been in post since November 2019 and completed her registration with CQC on 17 February 2020.

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. This included a monthly report the provider was required to send us after enforcement action was served at the last inspection. We reviewed information we had received from relatives, staff and members of the public. We sought feedback from the local authority and professionals who work with the service. The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report.

During the inspection

We spoke with three people who used the service and five relatives about their experience of the care provided. We spoke with fifteen members of staff including the registered manager and nominated individual. We reviewed a range of records including all eight people’s care records, three staff files and multiple medication records. A variety of records relating to the management of the service, including policies and procedures were reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We spoke with two professionals who regularly visit the service.

Updated 4 June 2020

About the service

Jabulani is a residential care home providing accommodation and personal care for people with learning disabilities, autism, physical disability, mental health conditions and sensory impairment.

The service was a large home, bigger than most domestic style properties. It was registered for the support of up to 11 people. Eight people were using the service. This is larger than current best practice guidance.

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

Practice at the service placed people at risk of harm. We found the building was cold throughout the inspection and the hot water in some people’s bathrooms did not reach suitable temperatures. Where people and relatives had raised concerns of inappropriate care or treatment, these were not always followed up or investigated. People did not always receive their medicines as prescribed. Safeguarding was not always given sufficient priority. We found examples of people telling staff or management they had been verbally or physically abused. These had not always been investigated. The provider could not demonstrate that staff had been safely recruited.

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.

The service rarely applied the principles and values of Registering the Right Support and other best practice guidance. These ensure that people who use the service can live as full a life as possible and achieve the best possible outcomes that include control, choice and independence. The outcomes for people did not fully reflect the principles and values of Registering the Right Support for the following reasons, lack of choice and control, limited independence and limited inclusion.

Care and support plans did not reflect the most recent evidence-based guidelines or best practice guidance. Staff were not adequately trained, and some did not have the skills or competency required. There was not always bespoke training to teach staff how to meet people’s individual needs. For example, where people had certain health conditions or autistic spectrum disorder, staff had not received training to meet their individual needs.

Privacy and dignity were not respected, this included when people were asleep. People’s independence was not promoted. People were not supported to enhance their life skills. For example, they could not go into the kitchen unless staff unlocked the door for them. The provider did not make independent advocacy available to people. The registered manager showed a lack of understanding about independent advocacy. Staff were instructed to be task focused and companionship was not promoted.

People did not have choice and control of their own lives. People had restrictions on their freedom that were not assessed and had not been agreed as in their best interest. People were not always supported to follow their interests or to take part in activities that were relevant to them. Visiting restrictions had been put in place on relatives and people who had raised concerns had been told they were no longer allowed to enter the premises. This meant some people were unable to spend time with their families in the home. The provider’s response to complaints did not demonstrate they took people’s complaints seriously and treated them with equality.

People told us the service was not well-led. There were low levels of staff satisfaction and the provider did not demonstrate an understanding of the importance of promoting people’s human rights. This meant people’s needs were frequently overlooked. Staff told us the newly appointed registered manager offered them more support than they had experienced before but staff, relatives and some professionals raised concerns with us about the conduct and manner of other senior members of the management team. Feedback we received was that people, staff, relatives and professionals at times felt intimidated, victimised and bullied. Systems and processes to assess, monitor and improve the quality and safety of services provided were ineffective.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was Inadequate (published 03 October 2019)

The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection, not enough improvement had been made and the provider was still in breach of regulations. We have used the previous rating and enforcement action taken to inform our planning and decisions about the rating at this inspection.

The service remains in special measures.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

You can see what action we have asked the provider to take at the end of this full report.

Enforcement

We have identified breaches in relation to person-centred care, dignity and respect, safe care and treatment, safeguarding people from abuse and improper treatment, handling of complaints, good governance, staff training and recruitment of staff at this inspection. In response to this we served notice of our decision to cancel their registration with CQC. This action has now been completed and the provider is no longer able to provide accommodation for people who require nursing or personal care from this location.