10 May 2019
During a routine inspection
People’s experience of using this service: People were at increased risk of harm, because of how the service had been managed. Medicines had not been managed safely. The provider had not made sure staff had the training needed to provide people with safe care and support.
There had been a high turnover of staff. Problems with organisation of the rota and staffing levels had led to missed visits and people’s care being cancelled.
Management had not always responded appropriately to safeguarding concerns and other incidents including missed visits. This meant opportunities to learn lessons and improve the service were missed.
Staff were not adequately supported to provide person-centred care. Care plans and risk assessments did not always reflect people’s needs or have enough information to guide staff on how those needs should be met.
People were not supported to have maximum choice and control of their lives; the policies and systems in the service did not support this practice. Consent to care was not explored or documented when people lacked mental capacity.
People were supported by kind and caring staff, but the organisation and leadership of the service effected the overall quality of the care people received.
New directors had taken over management of the service since our last inspection. A manager was in post, and they had applied to become the registered manager. The new providers and manager had not adequately monitored the quality and safety of the service. People and staff raised concerns about poor communication, organisation and leadership. There were widespread issues and concerns about the quality and safety of the service provided.
For more details, please see the full report which is on the Care Quality Commission’s (CQC) website at www.cqc.org.uk.
Rating at last inspection: At the last inspection service was rated Good (report published 29 November 2017).
Why we inspected: This inspection was planned in response to concerns about the service provided.
Enforcement: We have identified breaches of regulation in relation to the safety of the care provided, how the provider safeguarded people from abuse and avoidable harm, the quality of person-centred care, recruitment practices, staff training and the governance of the service. Please see the action we have told the provider to take at the end of this report.
Follow up: We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will monitor the progress of the improvements working alongside the provider and local authority. We will return to visit as per our re-inspection programme. If any concerning information is received, 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 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.
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.