The Care Quality Commission (CQC) has rated Cranmore and Stepping Stones, two care services in New Romney, Kent, inadequate, following inspections which took place in May.
Stepping Stones is a residential care home providing personal care to four adults with a learning disability or autistic people. Cranmore is a residential care home providing personal care to six people with a learning disability, autistic people, or those with complex needs. Both services are owned by Flarepath Limited.
Both Stepping Stones and Cranmore were rated inadequate overall and also rated inadequate in relation to whether they were safe and well-led.
Following the inspection, CQC imposed urgent conditions upon both services. The conditions restrict new admissions into the services and require the management to ensure their infection control practices are immediately improved.
At Cranmore, the provider must also ensure that they effectively manage risks in relation to any potential safeguarding issues, and assessments must be carried out to ensure the environment is safe for its intended purpose. This includes the safe storage of fire extinguishers and trip hazards.
CQC has asked for written documentation from the provider setting out how it will ensure these changes are made.
Deborah Ivanova, deputy chief inspector for people with a learning disability and autistic people, said:
“The reports for Stepping Stones and Cranmore make for distressing reading. Clearly neither service is meeting the underpinning principles of right support, right care, right culture or providing people with safe care.
“People with learning disabilities and autistic people have the right to support that meets their needs and enables them to live their best lives. Those running services should be doing everything in their power to ensure that this happens. In this case, one person living in Stepping Stones said they would rather be in hospital than in the service, because they would get better care. This is not acceptable under any circumstances.
“We have taken the action we feel is appropriate and expect significant improvements are made with immediate effect. We will continue to keep both services under review and will re-inspect within six months to check to see whether improvements have been made. If improvements have not been made at that point, we will decide what further enforcement action we will take in accordance with our legal powers.”
At Cranmore inspectors found:
- The culture of the service was poor with staff speaking to people in a derogatory way for example, calling them 'silly' and saying people 'threw paddies'
- People had been unlawfully restrained using incorrect techniques and there was no evidence that welfare checks had been completed on people following these episodes
- People's human rights had not been upheld, with examples or people having no curtains in their bedrooms. These had not been re-ordered or alternative items ordered. This infringed on people's dignity
- People had unnecessary restrictions placed on them, such as not having access to toilet paper and being locked out of the kitchen
- People were unlawfully physically restrained by staff who were not using the correct techniques
- Staff were not trained in positive behaviour support, and punitive practices such as not allowing people to get magazines due to behaviours were used
- Poor approaches to supporting people increased the use of physical restraint.
At Stepping Stones inspectors found:
- People and staff were at risk of harm from inappropriate of restrictive physical intervention. People with behaviour that was challenging were not supported in line with current best practice regarding the use of physical intervention
- People were not supported in line with current best practice in Positive Behaviour Support. The provider failed to recognise the use of seclusion when people were ‘sent to their bedrooms’. The provider had not notified the local safeguarding authority and CQC of all safeguarding concerns. One person had broken a finger during an incident which included the use of restrictive physical interventions this had not been investigated or reported externally
- There was a negative closed culture at the service, this placed people at risk of psychological abuse
- Staff lacked the understanding, skills and knowledge to support people with learning disabilities and complex needs
- Staff treated the people in their care like children and failed to give them the choice and control over their lives
- Some people's risk assessments detailed that garden tools should be locked away when not in use, but inspectors found the garden was littered with dangerous objects; broken chairs and uneven surfaces.
Full details of the inspection are given in the report published on our website: