CQC takes action to protect people at Berkeley House, Sittingbourne

The Care Quality Commission (CQC) has taken action to protect people at Berkeley House in Sittingbourne, Kent following an inspection in October.

Berkeley House is a residential care home providing personal care to up to 19 people with learning disabilities or autistic people, run by The Regard Partnership Limited (part of the Achieve Together brand). At the time of the inspection, 16 people were living there, in four separate houses: The Windmill, The Granary, The Bakery and Pippin.

CQC carried out an unannounced focused inspection on 20 October, after concerns were raised about poor leadership of the service, poor risk management, people not being kept safe from abuse or harm, and people living in poor, unsanitary conditions.

Following the inspection, the overall rating for the service deteriorated from requires improvement to inadequate and it was placed in special measures. Safe and well-led also deteriorated from requires improvement to inadequate. Caring, effective and responsive were not rated during this inspection.

Immediately after the inspection, CQC imposed urgent conditions on the provider’s registration and seven people were supported to move out of The Bakery while CQC worked with the local authorities to ensure those who remained there were kept safe from harm.

During this time, CQC received further information of concern, which led inspectors to reinspect the service on 28 October. Following the 28 October inspection, The Regard Partnership Limited informed CQC that it was going to close the home with immediate effect.

Debbie Ivanova, CQC’s deputy chief inspector for people with a learning disability and autistic people said:

“We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, and independence that most people take for granted. Yet when we inspected Berkeley House, we found people were living in appalling conditions.

“After our first inspection, we told the provider it must make urgent improvements, and imposed conditions on the service to ensure that these were made. However, after we went back in to inspect on 28 October, The Regard Partnership Limited chose to close the service with immediate effect, giving the authorities and families very little notice to find alternative accommodation for the people living there and causing extreme angst and distress to residents and their families.

“Daily life for people who called this service home was not dignified. In The Bakery, people were living in inhumane conditions, as their basic needs were not being met. There was no toilet roll in the bathrooms as it was locked away in a cupboard that only the manager had access to. People’s bedrooms were dirty, faeces was found on people’s pillows and bedding and on a chair, and one person’s bedroom had a strong smell of urine. Bedsheets were dirty, and in some cases, people had no bedding at all. Some people were wearing clothes that were too small for them.

“Some staff spoke to people in a harsh degrading way, telling people to keep out of their personal space with no explanation. People’s belongings weren’t respected, and furniture that was damaged when staff had been careless wasn’t replaced. One person had no blinds or curtains and their window was fixed open leaving them exposed to extreme weather.

“There were not enough suitably qualified and experience staff in the service to support people’s individual care needs, and the culture within the service was poor. Basic checks had not been carried out to ensure that people were living in clean, hygienic conditions and their human rights were being met. People were not encouraged to be part of the local community as there were not enough staff to support them to go out.

“It was clear there had been no improvement since our previous inspection. Instead, the service had been allowed to deteriorate and the provider had failed to recognise a closed culture had developed within the service, as people were not being treated with dignity or respect and they were at risk of harm."

Inspectors found the following during this inspection:

• The provider had failed to address the wellbeing of staff and people in the service. Staff morale at the service was low. Staff said there had been frequent changes in management and they had felt unsupported and not listened to
• The provider had consistently failed to monitor the service. There had been no review of incidents or action taken to prevent accidents, and they continued to happen. Care plans and risk assessments had not recently been reviewed or updated, even after an incident occurred
• Documentation was not accurate and did not reflect people's care needs. For example, one person's health care plan detailed a health condition that they did not have, and serious health conditions had not been detailed in other people's care plans
• People's specific health needs were not always risk assessed and well managed. One person lived with epilepsy and had been prescribed medicine to help control their seizures, but there was no guidance for staff on how or when to use the medicine, so they were not confident to administer it. When epilepsy is not well managed and controlled it can lead to life changing injury or death. One person was at high risk of blood clots. This was not in the person’s care plan and there was no guidance for staff to support this person. The person was not able to verbally communicate any health concerns they had and relied on staff for support and knowledge regarding this. When the risk of blood clotting is not managed or monitored it can lead to the person developing complications such as heart failure
• People in the Bakery House were living in unclean and unsafe conditions and they were not protected from the risk of harm or abuse. People’s basic human rights were not upheld as they were unable to access toilet paper
• Safeguarding incidents had not been consistently recorded or reported to the local authority safeguarding team so they could be investigated. The provider had failed to submit notifications about allegations of abuse to CQC
• People were restricted without any legal authority and they were not always supported to be as independent as possible. A staff member was observed forcing a person into their wheelchair against their wishes
• The provider had not followed legislation in relation to the Mental Capacity Act. When people lacked the capacity to make complex decisions about their own care, they were not supported to make decisions and did not have their rights upheld
• Staff did not have the skills required to interact or engage with people. There was no guidance in place to inform staff on how to reduce or de-escalate behaviours people may display. Staff said some people were scared of each other and would go to their rooms to hide when other people displayed anxiety and distressed behaviours. They also described incidents that happened between two people in the service and, although they knew that one person would retaliate, they did not recognise that it was their responsibility to intervene before the situation escalated
• Potential risks from the environment had not been highlighted and rectified. Unsafe flooring in people's bedrooms was a trip hazard. A draw in the kitchen contained sharp equipment and was not locked, as the lock had broken
• Some staff were not wearing face masks, or not wearing them correctly, and inspectors found used and discarded masks in people’s bedrooms and the garden, which posed a risk of the spread of infection.

Full details of the inspection are given in the report published on our website.

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