Archived: Rother Heights

Updated 16 August 2019

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

Three inspectors visited on each day of the inspection and a specialist pharmacy inspector visited on the second day of the inspection.

Service and service type

Rother Heights is a ‘care home’. People in care homes receive accommodation and nursing or personal care as 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 no manager registered with the Care Quality Commission. A registered manager 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.

The inspection activity started on 19 June and ended on 20 June. Three inspectors visited all of the bungalows and one house on 19 June and 20 June and a specialist pharmacy inspector visited two bungalows on the 20 June 2019.

What we did before the inspection

We used the information the provider sent us in the 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 sought feedback from partner agencies and professionals and through our own on-going monitoring such as information received by the provider. We used all this information to plan our inspection.

During the inspection

During the inspection we spoke with 12 staff, one temporary manager, one operational lead, two area managers, two quality leads and one admin assistant. We looked at a nine care plans, all of the staff training information, accidents and incidents, five medicines records, and governance systems and processes.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at training data and quality assurance records. We spoke with several commissioner and other stakeholders, and the local fire safety authority.

Updated 16 August 2019

About the service

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

Rother Heights can accommodate up to 28 people. At the time of our inspection 23 people were using the service. The service comprises of a complex of four bungalows and an office block. Each bungalow has six bedrooms with en-suite facilities. There are also two other houses nearby which can each accommodate up to two people.

The service has not been developed and designed in line with the principles and values that underpin Registering the Right Support and other best practice guidance. This ensures that people who use the service can live as full a life as possible and achieve the best possible outcomes. The principles reflect the need for people with learning disabilities and/or autism to live meaningful lives that include control, choice, and independence. People using the service were not receiving planned and co-ordinated person-centred support that was appropriate and inclusive for them.

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

People were not safe. They were not adequately or effectively protected from the risk of abuse. The registered provider had a system in place to safeguard people from the risk of abuse. However, systems to keep people safe had failed and safeguarding referrals were not always made. Staff did not always communicate effectively to ensure safeguarding concerns were reported to the safeguarding authority. Safeguarding referrals were not consistently made to the local authority safeguarding team when allegations of abuse were made, or incidents were witnessed in the service. During this inspection we identified safeguarding concerns which were reported to the safeguarding authority and an incident that we asked the provider to report to the Police.

The service did not consistently comply with their duty to inform CQC of information relating to the safety of people.

Medicines was not always administered safely. Some medicines prescribed 'as required' were not being managed effectively to ensure people received these as prescribed to ensure peoples safety.

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 identified there was an excessive use of restraint taking place, without consideration of people’s best interests.

There was a lack of regard for people’s human rights. There was a culture in the service where people were not respected as individuals and their rights were not upheld.

Risks associated with people's care and treatment were not always identified or managed safely. This put people at significant risk of not receiving the right support to meet their needs and showed the registered provider was not doing all that was reasonably practicable to mitigate risks associated with people's care and treatment.

We completed a tour of the home and found a number of environmental risks which had been identified by us on a previous inspection had still not been addressed. We found risks in relation to fire safety had still not been adequately managed.

Accident and incident analysis were still not sufficiently taking place and there was no evidence that trends patterns were being identified, or that actions had been taken to reduce hazards in relation to people's care and treatment. Analysis that had taken place was not effective as it didn’t show a true reflection of the number of incidents that had taken place or take in to consideration the impact from the severity of incidents to reduce risk to people and improve their well-being.

People were not always provided with access to healthcare professionals.

The provider had not ensured that staff received training to carry out their role. Training that had been completed was not effective. Staff told us they received one to one session with their line manager but told us they didn’t feel listened to, so this was also ineffective. We also found there were not enough suitable staff to support people. A large number of regular staff were leaving and there was a high use of agency staff who were not adequately trained to support people who needed specialist interventions to keep them and others safe.

People's needs, and choices were not always assessed, and care and treatment were not always delivered in line with current legislation and best practice standards.

Staff told us people were supported to receive adequate nutrition and hydration that met their needs. There was a plentiful supply of food available, but we saw that people’s choices of what they would like to eat and where they could eat meals being restricted by staff.

We spent time observing staff interacting with people and found there were some kind and caring interactions taking place, however this was not consistent. We also observed some undignified interactions between staff and people. Staff were waiting for incidents to occur rather that ensuring the correct support was in place to minimise triggers which may cause distress to people. People’s behaviour was seen first and foremost, this prevented people from being treated like as individuals in accordance with their own human rights. Staff were custodial in their approach to care for people rather than supporting them to live a full and active life.

Information about people was not kept confidential.

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. People were restricted by lack of choice, control and community participation, there was limited staff which prevented people from being able to access the community when they chose.

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

Rating at last inspection for this service was inadequate (last report was published 14 February 2019)

At the last inspection we identified eight breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We asked the provider to submit copies of monthly reports for areas of particular concern. The provider had been submitting this information to the Commission.

At this inspection not enough improvement had been made or sustained and the provider was still in breach of regulations and the service had further declined.

Why we inspected

The inspection was prompted in part due to concerns received about staffing, practice concerns and risk. A decision was made for us to inspect and examine those risks.

This inspection identified eight continued breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and there were significant concerns about the suitability and safety of people.

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

The overall rating for the service has remained inadequate. This is based on the findings at this inspection.

We found evidence during this inspection that people were at risk of harm from the concerns we found. We made commissioners and other stakeholders aware of our concerns.

Enforcement

We identified eight continued breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Follow up

Following the inspection, we wrote to the provider requiring them to take urgent action to address these risks and protect people from further risks.

Due to the level of our concern, we made an urgent application to the Magistrates Court to immediately cancel the registration of this service. The Order was granted on 10 July 2019 and the remaining people living at the service were moved out that day.

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