The Care Quality Commission (CQC) has rated People in Action – 132 Manor Court Road care home in Nuneaton, inadequate and placed it in special measures following an inspection in February.
This unannounced inspection was prompted in part after being informed of an incident following which a person using the service died. The incident is subject to further investigation by the police, and CQC who are prepared to take further regulatory action. The information shared as part of the incident indicated further potential concerns about the management of the service.
The care home provides accommodation and personal care for up to eight people and was providing care for seven people at the time of the inspection.
As well as the overall rating dropping from good to inadequate following this inspection, it has also declined from good to inadequate for being safe, caring and well-led. The ratings for being effective 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 and re-inspected to check sufficient improvements have been made.
Rebecca Bauers, CQC’s director for people with a learning disability and autistic people said:
“We expect health and social care providers to guarantee people with a learning disability and autistic people the safety, choices, dignity, and independence that most people take for granted. When we inspected People in Action care home in Nuneaton, 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 provide staff with the resources to assess risks to people’s health and safety, and care plans lacked guidance and clarity for staff on how to manage the risks. For example, staff weren’t aware of the different types of epilepsy, the risks of a seizure, and preventative actions to take to keep people safe as it wasn’t included in risk management plans. One person’s care record stated they hadn’t had a seizure since 2021, yet inspectors were told by staff that the person had one last year. Staff also weren’t sure who should be contacted if someone was having a seizure due to an inconsistent epilepsy care plan.
“Additionally, we found people spent time by themselves and staff were sat together in a separate area. They didn't regularly check on people to see how they were or to have any communication, which may have caused them to feel isolated and alone. For example, one person spent a whole day in their room and staff didn’t attempt to interact with them, other than to give them their meal. This culture is totally unacceptable, and people deserve a higher standard of care.
“We have reported our findings to the provider, and they know what they must address. We’re working closely with the local authority to ensure people are receiving safe care and we will return to inspect the home. If sufficient progress hasn’t been made, we will not hesitate to take further action to ensure people’s safety and wellbeing.”
Inspectors found:
- People had limited opportunities to leave the service and pursue social interests within their local community. There was limited guidance to inform staff how to enrich people's lives through positive engagement and meaningful activities
- Risks associated with people's health and wellbeing were not always managed safely
- Where risks had been identified, some records contained conflicting information about how staff should manage these risks
- People were not always supported to have maximum choice and control of their lives, and staff did not always support people in the least restrictive way possible and in their best interests; the provider’s policies and systems did not support best practice
- People were not always involved in making decisions about their care
- There was limited consideration given to the varying ways people could be empowered to make everyday choices using different communication methods
- The service did not always have a person-centred culture which empowered people to achieve their goals and aspirations
- Systems were not operated effectively to identify if people were receiving person centred care in line with Right Care, Right Support, Right Culture.