Archived: Summerfield House

Updated 14 December 2021

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.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was undertaken by three inspectors and an assistant inspector. Three inspectors visited the home for one day whilst an assistant inspector made telephone calls to staff. One of the inspectors was on site for a short period of time to use a symbol-based communication tool.

We are improving how we hear people’s experience and views on services, when they have limited verbal communication. We have trained some CQC team members to use a symbol-based communication tool. We checked that this was a suitable communication method and that people were happy to use it with us. We did this by speaking to professionals involved in peoples care. In this report, we used this communication tool with two people to tell us their experience

One inspector visited the home on another two occasions.

Service and service type

Summerfield House 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 registered manager was absent throughout the first two days of inspection and then resigned. They have applied to deregister with CQC.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. 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. We used all of this information to plan our inspection.

During the inspection

We observed and/or spoke with four people who used the service about their experience of the care provided. We received feedback from two professionals. We spoke with the independent consultant who was supporting the home. We spoke with 13 members of staff including the director, nominated individual, acting manager, team leaders and care workers. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

We reviewed a range of records. This included four people’s care records and multiple medication records. We looked at two staff files in relation to recruitment and staff supervision. 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 and check people were safe. We spoke with local authority safeguarding and commissioning teams.

Updated 14 December 2021

About the service

Summerfield House is a residential care home providing personal care for up to five people with a learning disability or autistic spectrum disorder. At the time of inspection four people were living in the home and one person had temporarily moved back to their family home.

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

People were not protected from abuse. Incident records detailed physical, verbal and emotional abuse which had not been responded to. There had been no action taken following the incidents to prevent reoccurrences and ensure people were protected from the risk of abuse.

There was a widespread lack of recognition from the staff and provider about the inappropriate and abusive practices being undertaken. The culture of the service was such whereby incidents of abuse, resulting in harm, were deemed as normal.

The registered manager and provider had failed to ensure that monitoring and governance systems and processes were established and operating effectively to ensure compliance with the regulations. The provider failed to ensure there was effective and consistent managerial and operational leadership in place. The home presented with a closed culture meaning poor culture that led to harm, including abuse.

There had been no safeguarding alerts made to the local authority safeguarding team for numerous allegations of abuse. There had been no consideration of notifications needing to be made to the CQC in line with legal requirements.

Care plans and risk assessments weren’t always updated to consider how to support people. People were not supported to be involved or make decisions about their care. We were not assured of good infection prevention control practice in relation to COVID-19.

There were widespread concerns that people were not treated with dignity and respect. Staff practice, language and records were demining and derogatory to people. There was little understanding from staff in regard to poor practices and the impact on people’s wellbeing.

Care was not personalised to meet people’s needs, preferences, interests and give them choice and control. People were not involved in developing their care plan and their individual needs and circumstances were not considered. The registered manager and provider had not taken appropriate steps to comply with the Accessible Information Standard to ensure people’s communication needs were met.

There were widespread and significant shortfalls in the care, support and outcomes that people experience. The registered manager and provider showed a lack of understanding of how to apply the Mental Capacity Act 2005. The home did not work with professionals to ensure effective outcomes for people.

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 expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right Support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

The service was not able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture. The model of care did not maximise people’s choice, control and independence. Care was not person centred. The ethos, values, attitudes and behaviours of leaders and care staff did not ensure people using services lead confident, inclusive and empowered lives. This meant people did not receive person centred care, the provider and staff did not do all that was reasonably practicable to make sure peoples care and treatment was appropriate, met their needs and they had choice. We took action to address this. Full information about CQC’s regulatory response to the serious concerns found during this inspection is added to the report after any representations and appeals have been concluded.

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

Rating at last inspection

The last rating for this service was good (published 04 September 2019).

Why we inspected

The inspection was prompted due to concerns received about abuse. A decision was made for us to inspect and examine those risks.

We looked at infection prevention and control measures under the safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We have found evidence that the provider needs to make improvements. Please see all sections of this full report.

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

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to safe care and treatment, safeguarding people from abuse, person centre care and governance at this inspection.

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.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information 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 the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

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.