The Care Quality Commission (CQC) has rated 2M Health & Home Care Service Ltd, a domiciliary care service in Birstall, Leicester, inadequate and placed it in special measures following an inspection in May.
This inspection was prompted in part due to concerns we received about personal care, incident reporting and escalation, and medicines management.
The service provides personal care to autistic people and people with a learning disability and other people living in their own homes. At the time of our inspection there were 32 people using the service.
Following this inspection, the service’s overall rating has dropped from good to inadequate, which is the same for safe and well-led. Effective, caring and responsive have dropped from good to requires improvement.
The service is now in special measures, which means it will be kept under close review by CQC to keep people safe and re-inspected to check sufficient improvements have been made.
Craig Howarth, CQC deputy director of operations in the midlands, said:
“We expect health and social care providers to guarantee autistic people and people with a learning disability the safety, choices, dignity, and independence that most people take for granted. When we inspected 2M Health & Home Care Service Ltd, we had concerns that these needs weren’t being met at the standards people should be able to expect. It wasn’t acceptable that leaders were allowing a culture to exist where people weren’t being given the opportunity to lead their best lives.
“We found leaders didn’t have an enough understanding of their roles. They didn’t ensure that care plans and risk assessments were effective and that staff had the training they needed. We also found that the provider failed to work with other agencies such as GPs and District Nurses. For example, an incident had occurred where a person needed medical assistance, however nothing was done until our inspector advised the manager to take action.
“Inspectors saw that risks weren’t assessed, monitored, or managed well by staff and care plans lacked detail about individual needs. For instance, people who were at risk of choking had no risk assessments in place for staff to support them to eat safely or know how to respond should there be an incident.
“Additionally, we saw people using the service weren’t fully protected from the risk of abuse and improper treatment as not all staff had received safeguarding training and there was a lack of record keeping. During the inspection, an incident occurred which wasn’t recorded or reported to the relevant agencies. This puts people at risk of harm from abuse.
“We have reported our findings to the provider, and they know what they must address. We will return to inspect the service to ensure people are receiving safe care. If sufficient progress hasn’t been made, we will not hesitate to take action to ensure people’s safety and wellbeing.”
Inspectors found:
- People were not always supported to have maximum choice and control of their lives as their care plans and risk assessments did not provide a full overview of their needs
- Staff did not always support them in the least restrictive way possible and in their best interests
- People who were known to display emotional distress or frustration did not have proactive positive behaviour support plans in place
- Staff were not equipped with the detail on specific actions to take to ensure practices were least restrictive to the person and reflective of a person's best interests
- People did not receive personalised care that reflected their needs and preferences. Care plans failed to provide staff with clear guidance on meeting people's diverse needs
- People's communication needs were not always identified within care records and the provider was unable to evidence how specific communication needs were met
- Governance systems did not ensure people were kept safe and received a high quality of care and support in line with their personal needs
- The provider was unable to demonstrate all staff had received training in relation to the Mental Capacity Act 2005 (MCA).