Background to this inspection
Updated
20 September 2019
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. This inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Act, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.
Inspection team:
This inspection was carried out by one inspector and a specialist advisor with a specialism in mental health. A specialist advisor is a professional who assists us with current practice knowledge and expertise on inspection.
Service and service type:
Dearman Road is a registered care home without nursing. 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.
What we did:
Before the inspection, we reviewed information we had received about the service since the last inspection. This included any notifications we had received from the service and feedback we requested from external agencies including the local authority and Healthwatch. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. We also took into account a serious incident which had occurred at another service registered with the provider.
Providers are required to send us key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We referred to this information to help plan our inspection.
During the inspection, we spoke with one person, three support workers, the registered manager and a new Service Manager. We also reviewed records related to two people’s care and record related to medicines management, health and safety and quality assurance.
Some information we requested was not available to view during our inspection, including the training matrix, recruitment files and incident records. We were told these records were stored at the provider’s head office. The provider sent these to us after our inspection.
Updated
20 September 2019
About the service: Dearman Road is a respite service offering accommodation and support for people with mental health support needs. Two people were supported at the time of the inspection.
People’s experience of using this service:
Staff showed awareness of people’s safety and risks, and demonstrated a caring approach. A person we spoke with told us they felt safe. They spoke positively about the service and the support of staff. People’s privacy and independence was promoted. People were given choices and support to access further support from their mental health teams when needed. However, the provider’s systems failed to ensure the quality and safety of the service with particular concerns as follows:
• People’s risks had not been effectively assessed, including in relation to ligature risks at the premises. The provider’s environmental risk assessments had not been completed robustly and action to improve the safety of the service had not been completed to the provider’s own timescales.
• Health and safety checks were not completed robustly to ensure the safety of the service including in relation to fire safety.
• Incidents were not effectively investigated and used for learning to improve the safety of the service.
• Please see more in Detailed Findings below.
Rating at last inspection: Requires Improvement (November 2017)
Why we inspected: This was scheduled inspection based on the previous inspection rating.
Enforcement We identified two breaches of the Health and Social Care Act (Regulated Activities) Regulations 2014 around safe care and treatment and governance. We also identified a breach of the Care Quality Commission (Registration) Regulations 2009. Details of action we have taken can be found at the end of this report.
Follow up: During our inspection, we prompted the provider to address our safety concerns and to provide us with updates after the inspection. We shared our concerns with the local authority and commissioning team that arranges referrals to the service. 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.
The overall rating for this registered provider is ‘Inadequate’. This means that it has been placed into ‘Special Measures’ by CQC. The purpose of special measures is to:
• Ensure that providers found to be providing inadequate care significantly improve.
• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.
• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration, if we have not taken this enforcement action already.
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 the service. This will lead to cancelling their registration or varying the terms of their registration within six months if they do not improve and similar action may have been taken already. This service will continue to be kept under review and, if needed, could be escalated to further urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.