CQC's response to the safeguarding adult review of Mendip House

The Care Quality Commission has welcomed the publication of the Safeguarding Adult Review of Mendip House in Somerset.

The review was commissioned by Somerset Safeguarding Adult Board following allegations of mistreatment and abuse of some residents by a number of staff. Mendip House was a bungalow used as a care home for six people with complex needs, one of seven registered locations provided by the National Autistic Society at Somerset Court. Link to Review

In May 2016, CQC had received safeguarding concerns raised by a member of staff. An urgent inspection found a chaotic management, and multiple breaches of statutory regulations, leading to a rating of Inadequate in all five key questions. Read the full report of the inspection.

As a consequence of the inspection, we decided that we should start the process to cancel its registration. NAS decided to close Mendip House and the location was removed from their registration in November 2016.

Andrea Sutcliffe, Chief Inspector of Adult Social Care, said: "Everybody living at Mendip House should have been treated with dignity and respect; instead they were abused and intimidated by their care staff. As the Safeguarding Adults Review makes clear, the National Autistic Society is primarily responsible and accountable for this.

"I am disappointed that the society, which has a proud history of championing the rights of autistic people, allowed this bullying culture to prevail. All providers need to be vigilant and ensure a culture that treats the people they support with dignity and support is sustained and not left to chance.

"When CQC inspected in May 2016 we found a service that was managed so badly that we rated it as Inadequate. Quite clearly it could not be allowed to continue. Our action to cancel the registration of Mendip House was overtaken by the NAS decision to close the service; a decision that we supported.

"Our own internal review has identified that we should have done more when concerns were first raised with us. We referred those concerns to the local safeguarding authority but we were too ready to accept assurances from Somerset County Council and the National Autistic Society that they had been dealt with. I am sorry that we did not act sooner to protect the residents of Mendip House.

"We welcome the report and we share the Board’s concerns over the outdated design of services like Mendip House. As our report Registering the Right Support (LINK) makes clear, these dayswe would be unlikely to register a new service like this, and we are committed to monitor those services that already exist ever more closely."

Action taken by CQC since May 2016

Mendip House

• 9 May 2016 - CQC received whistleblowing concerns from an agency staff member. The lead inspector made a safeguarding referral on the same day. Somerset County Council reported they had received a number of concerns the previous week.
• 12 May 2016 - CQC carried out an urgent focused inspection at Mendip House to review action taken by the provider to ensure people’s safety. We were satisfied that the staffing arrangements were adequate to keep people safe and ensure continuity of the service.
• We decided to carry out comprehensive inspections of all Somerset Court locations, including Mendip House.
• 14 June 2016 - comprehensive inspection. Mendip House was rated Inadequate in all five key questions and Inadequate overall. (The report was published on 5 August 2016)
• 19 July 2016 - CQC made the decision to serve a Notice of Proposal to remove the location Mendip House from the provider’s registration.
• 27 July 2016 - NAS informed CQC they intended to submit a voluntary application to remove the location Mendip House. CQC accepted this application as the NOP to cancel the registration had not been served.
• October 2016 – Mendip House closed, and all residents had moved to new homes
• November 2016 – Registration was cancelled

Somerset Court

Mendip House was one of seven registered locations provided by the National Autistic Society at Somerset Court (50 beds in total) near Highbridge in Somerset. We continue to monitor the six remaining care homes at Somerset Court; five are rated Good, one is Requires Improvement. There is also a domiciliary care service rated Requires Improvement.

Blackdown House (Requires Improvement, June 2017)

Following inspection in June 2016, we served one Warning Notice in relation to safe care and treatment. We returned to Blackdown House in September 2016 to ensure action had been taken. We carried out an inspection of Blackdown House in June 2017, when we found two breaches of the Health and Social Care Act. The location is rated Requires Improvement in four of the five key questions. We continue to review all information on this service from a range of sources and will inspect unannounced during 2018.

Cotswold House (Good, August 2016)

Greatwood House (Good, July 2016)

Latest inspection found services Good overall but Requires Improvement in Safe. Although people were protected from abuse, there were some potential risks associated with the management and administration of people's medicines.

Lakeside House (Good, October 2017)

During inspection in September 2016 the service was rated Requires Improvement in Effective and Well Led, with four breaches in regulation – Mental Capacity Act, supervision, premises and quality assurance systems. At the last inspection in October 2017, we found all required improvements had been made and rated the service good.

Knoll House (Good, March 2017)

Our most recent inspection found the service Good overall, but Requires Improvement in Effective. People's legal rights in relation to decision making were not always upheld.

Porlock House (Good, July 2016)

NAS Community Services (Somerset) (Requires Improvement, February 2017)

During our inspection in September 2016, we found five breaches of regulations. We issued Warning Notices in relation to effective and well led. When we re-inspected in February 2017 we found action had been taken to improve in those areas although the overall rating remained requires improvement. The service was inspected in January 2018 and the findings will be published in due course.

National Autistic Society

NAS has 43 residential and community service locations currently registered, providing around 250 beds. Nationally eight NAS services are rated RI, 30 are good, one is outstanding. Four services have not been rated: two are dormant and two are awaiting their first inspection (as February 2018).

CQC has met the chief executive of the National Autistic Society on a number of occasions to assure ourselves that the society has responded to the concerns raised by Mendip House in the management of its other services. We want to ensure that that all NAS locations are delivering the quality of service that everyone has a right to expect.

We have reminded lead inspectors to review the latest information we hold on NAS services, including intelligence from commissioners taking account of the issues and risks identified at Mendip House, checking any services that have not made recent notifications.

In their assessments, inspectors are required to pay particular attention to where people are accommodated in outdated models of provision (as set out in Registering the Right Support) and where we know people are placed out of county.

Services for people with a learning disability and/or autism

CQC recognise that some outdated models of care present a higher risk to people who live in these services and require closer monitoring by inspectors.

Since the BBC Panorama programme which exposed the abuse of people at Winterbourne View hospital, there has been increased scrutiny of how we meet the needs of people with a learning disability or autism.

In October 2015, NHS England and others published Building the Right Support, a national plan to develop community services, later setting out a clear picture of what good quality care models should look like. There was agreement that care in institutional settings is rarely person-centred and can lead to abusive practices, too often in locations that are out of sight of commissioners and people’s families, friends and communities.

In February 2016, our policy statement Registering the Right Support made it clear that it was unlikely that we would register this campus model now when considering applications for services for people with a learning disability and/or autism. Following a period of public consultation, our guidance was further clarified and strengthened in 2017.

In October 2017, we reminded inspectors that this design of service is inherently of higher risk. Our internal guidance advises that in reporting on those existing services, inspectors should reflect where a service does not conform to Building the Right Support and Registering the Right Support.

As part of our response to the Mendip House SAR, inspection managers in the South West have met to consider the circumstances in this case, and the findings from this review are being shared with all inspectors and managers across CQC.

Response to Somerset SAR recommendations

The Safeguarding Adult Review (LINK) makes a number of recommendations that include:

• the Department of Health, NHS England and the Local Government Association are requested to…assert a new requirement to discontinue commissioning and registering “campus” models of service provision

  Our response: The responsibility for registering services that provide regulated activities rests with CQC.cOur published guidance already makes it clear that it is unlikely that we would register this campus model of services now when considering applications for services for people with a learning disability and/or autism. CQC‘s policy Registering the Right Support (February 2016) takes account of Building the Right Support published by NHS England in October 2015. Following a period of public consultation, our guidance was further clarified and strengthened in 2017.

  In any application for services for people with a learning disability and/or autism we would expect providers to demonstrate that their proposals comply with the principles of this guidance and the accompanying service model, or to explain why they consider there are compelling reasons to grant an application despite it departing from best practice guidance.

  CQC will assess applications for all new learning disability services, including care homes and supported living, to ensure that the provider has taken account of this model in designing their services.

• Since it is unlikely that the Care Quality Commission would register this model of service now, Somerset Safeguarding Adults’ Board should write to the Care Quality Commission requesting that it (a) makes this fact explicit in its inspection reports; (b) undertakes more searching inspections of such services; and (c) does not register “satellite” units which are functionally linked to “campus” models of service provision

  Our response: a) Our own internal report-writing guidance (updated October 2017 to include this reference) advises that in reporting on existing services, inspectors should reflect where a service does not conform to Building the Right Support and Registering the Right Support. Our guidance notes that it is very difficult for large services for people with autism to meet the standards.

  b) We welcome this recommendation since it aligns with our existing strategy of taking a more risk-based approach to the way we monitor and inspect services. We recognise that services of this kind (for instance those based on old fashioned models of care, out of county commissioners, campus provision) are inherently of higher risk by their very nature. We are already taking action to ensure that inspectors and inspection managers focus on closer monitoring of these services and consider responsive inspection when information is received from staff, people using the service, other professionals or family members.

  CQC already has regard to the policy Registering the Right Support when reporting on and rating services.

  At a local level, inspection managers have met to consider the circumstances in this particular case, and the findings from this review are being shared with all inspectors and managers across CQC.

  c) See above. It is unlikely that CQC would register this campus model of services now.

• A Memorandum of Understanding is negotiated by Somerset County Council whereby the aggregate-level information concerning grievances, disciplinaries and complaints, for example, gathered by providers is shared with the Care Quality Commission and pooled with that of local authorities’ safeguarding referrals, the “soft intelligence” of Clinical Commissioning Groups, the police and prospective commissioners. The "search costs" of information seeking, negotiating access, processing and storing are excessive – this is most particularly the case when Section 42 inquiries are invoked

  Our response: CQC has a national agreement in place with ADASS to share information between CQC and local authorities and this happens across the country. We welcome the strengthening of local arrangements with Somerset County Council to improve the pooling of information that will improve the monitoring and oversight by CQC, local safeguarding authorities and commissioners.

• The Care Provider Alliance, with the support of the Care Quality Commission and Skills for Care, issue its members with guidance on how the role of responsible or nominated individual in supervising the management of the regulated activity83 should be performed in respect of quality assurance and safeguarding.

  Our response: CQC provides guidance to providers on requirements set out in the care standards in respect of good governance (including quality assurance) and safeguarding. This is available on our website. We welcome the opportunity to work further with the Care Provider Alliance and Skills for Care to ensure that nominated individuals understand their responsibilities and implement them accordingly.