The Care Quality Commission (CQC) has rated Gracefield Health Care Limited (GHC) – 31 St Domingo Grove in Anfield, Liverpool, inadequate and placed it in special measures.
A focused inspection was carried out in January and February to look at how prepared the service is, with preventing or managing a COVID-19 outbreak. Due to issues found with infection prevention and control measures as well as the environment, the inspection was widened to include all areas - whether it is safe, effective, caring, responsive and well-led.
Following this inspection, the overall care home rating has dropped from good to inadequate and the service has been placed in special measures. The service is also rated inadequate for being safe, effective, caring, responsive and well-led.
Issues identified during the inspection were in relation to safe care and treatment, safeguarding people from abuse, consent, recruitment practices, person centred care, governance and treating people with dignity.
St Domingo Grove is a residential care home providing accommodation for up to six people who require nursing or personal care. The service provides support to people with a learning disability, autistic people and people with mental health support needs.
Hayley Moore, CQC’s head of adult social care inspection, said:
“We carried out an inspection of St Domingo Grove to look at their infection prevention and control measures. However, due to significant issues found, we widened the inspection to look at all key areas to check the quality of care being provided.
“During the inspection, we found people were at risk of serious harm as the service wasn’t well-led. The registered manager wasn’t aware of incidents involving physical restraint, which meant there wasn’t any oversight to ensure these practices were the most appropriate intervention or that they were carried out safely.
“Someone told us they had been physically and verbally abused by a member of staff and despite raising this with the manager, no action was taken. We shared our concerns with the local safeguarding team and ensured the provider took immediate action to protect the person. Also, when people had unexplained bruising there was no follow up action taken and there was no evidence staff shared these concerns with relevant partner organisations.
“We observed staff walking through the home and touching surfaces prior to completing a COVID-19 test before starting work. This increased the risk of infection spreading to people living at the home. Additionally, the home wasn’t clean and hygienic, carpets, doors and handrails were dirty, one person's mattress was heavily stained, and another person's duvet was soiled.
“We were concerned that people's privacy, dignity and independence were not respected. During the inspection, we observed a person on the toilet with the door open and three staff members present. Inspectors could walk past with no warning or consideration of the person’s privacy or dignity. One person's bedroom had no bed linen, ripped curtains, a smashed window, no toilet seat, damaged walls and clothes were lying on a chair as they had no access to a wardrobe. The person was visibly upset with living in this environment, which is totally unacceptable. The provider did inform us that plans were in place to carry out a refurbishment to improve these conditions.
“We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted, this was not always the case at St Domingo Grove.
“The provider has started to make some improvements and is aware where further changes are necessary to improve the standard of care for vulnerable people living at the home. We will continue to monitor the service closely to ensure people are safe. If we’re not assured people are receiving safe care, we will not hesitate to take further action.”
Inspectors found:
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
There were ineffective processes in place to protect people from abuse or improper treatment. People were exposed to serious risk of harm as their care needs and associated risks had not been routinely assessed, monitored and mitigated
Staff did not have the training or support needed to make the human rights-based decisions that would have helped them to provide better, safer care to autistic people and people with a learning disability. There was no involvement of professionals in the development of people's support plans or behaviour support plans. The provider did not always promote good health and wellbeing outcomes for people. People had access to local and community health services. However, people were not always encouraged to engage with these services
The environment was poorly maintained, and some people's bedrooms were quite bare and contained minimal personal items. People's privacy, dignity and independence were not respected, and people were not always supported to be involved in decisions about their care. Some people's communication care plans contained out of date information
People were supported to maintain relationships with people important to them. However, there was limited evidence that people were encouraged to develop relationships with people in the wider local community People's care needs were not regularly reviewed. People were therefore at risk as staff did not have the up to date information required to meet their needs
People were not safe in the event of a fire. There were significant concerns in relation to fire safety such as defective fire doors, the absence of regular fire drills, an overdue fire risk assessment and personal emergency evacuation plans lacked detail.
Full details of the inspection are given in the report published on our website.
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