The Care Quality Commission (CQC) has told Saxon Court, a care home in Uckfield, East Sussex, to make urgent improvements to keep people safe, following an inspection in July. The service has now been placed into special measures.
Saxon Court is a residential care home providing personal care to 18 people with learning disabilities or autistic people.
This focused inspection was undertaken due to concerns about staffing levels, and was also an opportunity to ensure that the service was applying the principles of right support, right care, right culture.
Fundamentally, staff and people using this service were being let down by poor leadership, which impacted on every area of this service.
At this inspection, CQC looked at how safe and well-led services were, both of these areas were rated as inadequate. Previously the service was rated as good for being safe and requires improvement for being well-led. This inspection also sees the service’s overall rating drop from good to inadequate.
Due to the level of concerns identified at the inspection, CQC notified the local authority who took action to provide support for staffing and review people's needs.
Debbie Ivanova, CQC’s deputy chief inspector for people with a learning disability and autistic people said:
“When we inspected Saxon Court, we found a service that wasn’t providing a safe home for people to live in. Despite the best efforts of staff, who were kind and caring, both they and people using the service were being let down by poor leadership, which impacted on every area of daily life for people living here.
“In particular the low staffing levels meant we saw a workforce stretched too thin to meet both the physical and emotional needs of people living here. As well as trying to provide support for people using the service, staff were also covering for a cook who didn’t work weekends, and a cleaner who was only hired on a part time basis.
“This didn’t leave staff enough time to do the things that really matter. They weren’t reporting potential safeguarding incidents to the local authority, helping people who needed support to move around to prevent falls, or fill in care plans so everyone knew how to support people as individuals. This led to an incident where someone choked on food which could have been avoided. Even following this incident their care plan was not updated to say how this would be avoided in future putting them at risk of potential avoidable harm.
“People using the service told us they were bored, and staff told us they didn’t have time to have meaningful interactions with people like sitting and talking to them or helping them to pursue their interests. People were left on their own for long periods of time with nothing happening. 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.
“All of this adds up to an environment which is best described as a closed culture. People are entitled to a life of their choosing which gives them the opportunity to fulfil their ambitions. This was not happening at Saxon Court. We expect to see urgent improvements being made and will monitor the service to make sure this happens. We won’t hesitate to take enforcement action to keep people safe if this doesn’t.”
Inspectors found:
- All aspects of the service were affected by the lack of staff. Staff, whistleblowers, and the local authority all told us that there were not enough staff to support people safely. One staff member told us that the service should be shut down because it isn’t safe
- There were no systems or processes to ensure people were protected from harm or abuse. Eight separate incidents were identified which should have been reported to the local authority safeguarding team and to the CQC. These included where a person had been involved in a choking incident and a physical altercation between two people. The provider didn’t know these incidents had not been reported and couldn’t tell inspectors why they hadn’t been. This demonstrated poor oversight of what was happening in their own service. There was also no evidence of analysis of incidents to identify themes or trends or any evidence of actions taken to prevent a recurrence
- There were poor processes in place for almost every area of work that was undertaken by staff. Staff told inspectors that the registered manager was rarely on site to provide guidance to them and they felt unsupported as a result
- Staff told inspectors that they had raised multiple concerns around staffing levels with the provider. They didn’t feel listened to, as issues were raised, but action was never taken. Staff were kind and caring but felt they were failing people by not being able to provide safe care or opportunities for them
- Locked doors and the environment of Saxon Court, including signage, meant it felt more like an institution than a home. This included people's personal information such as a poster on the wall which indicated what people's fluid requirements were and which care forms needed to be completed for each person
- Aspects of the environment were not safe. In one area of the service, the door thresholds were not flush to the floor. This meant people in wheelchairs had to be lifted by staff, over these thresholds to move between rooms. For people that walked independently and were at risk of falls, these were trip hazards
- Medicines weren’t being managed safely, putting people at risk of medication errors which may harm them
- People were not supported to have maximum choice and control of their lives and staff were not supporting people in the least restrictive way possible and in their best interests.
Inspectors found that people’s experience of living at the service was poor:
- It was clear that staff wanted to provide a good service for people but due to staffing issues did not have the time to provide good care. One staff member told inspectors; "It's heart-breaking. You want to spend time with people. For some people we are all they have, and we can't even sit for five minutes and hold their hand. We are failing them."
- Inspectors saw one person who was at risk of falls who wanted to walk around the service was frequently brought back to an armchair to sit down. Staff told inspectors they didn’t have enough time to walk with the person.
- People’s care plans detailed hobbies and interests but inspectors didn’t see any of these being supported. One person told us they were bored
- Staff wanted to do more activities with people but told inspectors they just didn’t have the time. When on inspection one staff member said two people would love to go out to lunch today but couldn't because there was no one to take them. The staff member commented, "People in prison get more opportunities than the people here."
- One person’s en-suite shower had been broken since February, but had still not been repaired at the time of this inspection in July.
Full details of the inspection are given in the report published on our website.
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