Regulator acts to protect safety and welfare of people in 14 care services

29 February 2012

The Care Quality Commission is taking action to protect people with learning disabilities who have been living in services operated by Atlas Project Team Ltd in the South of England.

CQC has told the company that it has serious concerns about seven of the care homes run by the group, and that a further six were not fully compliant with essential standards of quality and safety. CQC also has concerns about one supported living service. One Atlas service is fully compliant with all the essential standards.

Inspections at 14 sites operated by Atlas Project Team Ltd followed safeguarding concerns raised in October at the Veilstone care home at Buckland Brewer, near Bideford in Devon. 

Since then, inspectors have made unannounced visits to care homes registered to provide care for up to 58 people in Berkshire, Devon, and Hampshire.    Reports of the inspections of all 14 services checked have now been published on the CQC website.

CQC has been working closely with councils and NHS organisations to monitor the homes and to ensure that people living there are not at any immediate risk of harm.

Among the main concerns which CQC inspectors found were:

Santa Maria, Wokingham, Berkshire:

People's privacy was not protected. The home had failed to ensure that people were treated with dignity and respect.

While staff were aware of their duty to report any suspected abuse, the arrangements in place to manage behaviour were inappropriate because they could be excessive, putting people at risk of mistreatment.

The company had failed to ensure that staff had received appropriate training or supervision to be able to meet the needs of the people who used the service.

Gatooma care home, Holsworthy, Devon:

• Relatives and advocates were not properly involved in decisions relating to people's care and treatment. Staff did not always talk about the people they supported in a respectful, considerate and dignified way. Rights to autonomy and independence were not promoted.
• The care planning system was not person-centred and had not been developed with the people who live in the home or those acting on their behalf.  
• Staff knew what procedures to follow should an incident of mistreatment, abuse or neglect be suspected, although it was not evident that staff knew which practices constituted abuse. The management and staff team did not understand the current legislation and reporting procedures on restraint and deprivation of liberty.  

Santosa care home, Holsworthy, Devon:

• People were not involved in drawing up their own care and support plans and relatives or advocates were not properly involved in about their treatment or in decisions about managing their behaviour.  People's rights to privacy, dignity and independence were not always respected by the staff.
• The care home did not have suitable arrangements in place to ensure that staff were properly trained to enable them to deliver care and treatment safely and to an appropriate standard. 

Teignmead, Bishopsteignton, Devon:

• The care planning system was not person-centred and had not been developed with the people who live in the home and those acting on their behalf. The lack of a structured care planning process was putting people at risk of receiving care or treatment that was inappropriate or unsafe.
• The arrangements in place for managing behaviour were not protecting people from the possibility of excessive control being exerted by staff.

Chacedene, Southend Bradfield, Berkshire:

• The numbers of staff on duty were not sufficient to safely meet the needs of people living in the home when a person presented challenging behaviour.  Health and social care professionals' opinion on staffing levels had not been taken seriously by the home. This placed people at risk.

Orchard House, Ryeish Green, Berkshire:

• Atlas had failed to ensure that people were protected against the risk of receiving care or treatment that was inappropriate. They had failed to carry out an assessment of needs, and had not planned or delivered care that met people's needs or ensured their welfare or safety.

Veilstone, Bideford, Devon:   (published November 2011)

• The use of an unheated and unsuitable “quiet room” particularly for people to stay in overnight, did not uphold people's right to dignity, privacy and independence. Relatives or advocates were not properly involved in decisions relating to people's care and treatment.
• The lack of detailed risk assessments for each person on the use of the quiet room put people at risk of receiving care that was inappropriate or unsafe.

Ian Biggs, Deputy Director of CQC in the South said: “It is quite clear that the services run by Atlas Project Team Limited have been stuck in the past. The vulnerable people they were supposed to be protecting have not been getting the care which they need. 

“Our inspections have found that the services have been taking an old fashioned approach to care, with a strong emphasis on behavioural management and the routine use of physical restraint.    

“People’s behaviour appears to have been managed rather than understood. Staff had not always received training about the Mental Capacity Act or deprivation of liberty procedures and no external agencies had been involved in any consideration of liberty deprivations.

“In some locations, the managers and staff have shown no awareness of person-centred care planning. There had been no input from speech and language therapists to help determine the best communication strategies for individuals and current approaches for people with autism were not in use.

“The best that can be said of the model of care is that it is outdated. We cannot allow this to continue. We will now take action to protect the interests of the people who depend on these services. While the law does not allow us to go into detail at this stage, we will publish a full report in due course.”

Ends

For further information please contact the CQC press office on 0207 448 9401 or out of hours on 07917 232 143.

Notes to editors

1. The full reports of inspections are available here: http://www.cqc.org.uk/directory/1-1016635412
2. In November, the Care Quality Commission issued a formal warning to Atlas Project Team Limited that it must make urgent improvements to standards of care or face further action.    Inspectors found that the provider was failing to meet national standards covering the care and welfare of people, and respecting and involving people who use services. The Veilstone care home is now vacant and the provider has stopped all new admissions.
3. Where we have concerns we have a range of enforcement powers we can use to protect the safety and welfare of people who use this service. When we propose to take enforcement action, our decision is open to challenge by a registered person through a variety of internal and external appeal processes. We will publish a further report on any action we have taken.