The Care Quality Commission (CQC) has rated Inglewood House in Camberley, inadequate overall, following an inspection in April.
Inglewood House is a residential care home providing personal care for up to 12 people with a learning disability or autistic people. The service is run by Achieve Together.
CQC carried out an unannounced inspection after receiving information of concern indicating unsafe care was being delivered and people were not being protected from abuse. At the time of the inspection 11 people were living at the service.
Following the inspection, the overall rating for the service dropped from good to inadequate. The ratings for safe, effective, caring, responsive and well-led also dropped from good to inadequate.
The service is now in special measures which means it will be kept under review and re-inspected within six months to check that improvements have been made. If significant improvements have not been made, CQC will take further enforcement action.
Deborah Ivanova, CQC’s director for people with learning disability and autistic people, said:
“When we inspected Inglewood House, we found a service which wasn’t well run, with a manager who was trying to run the service remotely instead of being present to supervise staff. This lack of managerial oversight, which the provider wasn’t aware of, had led to several incidents of abuse which we were told about prior to the inspection. Although the provider took action once they became aware, we identified further instances of verbal and emotional abuse by staff. That should never have happened. It was also concerning that staff weren’t properly trained and didn’t always recognise or report abuse to the local authority so it could be investigated.
“What was most concerning is the way people were made to feel, in a place that was supposed to be their home. The people living there told us staff often seemed angry when they spoke to them which made them feel scared, and they stayed in their rooms, so they didn’t have to hear staff shouting. Relatives told us staff were bossy, rude and some were bullies. Vulnerable people were relying on staff to act as their advocates to keep them safe, and it is unacceptable the people they relied on were treating them this way.
“People’s individual needs to help them cope when they were anxious and stressed were often ignored, even though these were recorded in their care plans. For example, one person had strategies in place to help them cope when they were distressed, but when they were displaying this behaviour, a member of staff told them to stay in their room and reflect on their behaviour. Another person was nervous about shiny floors after experiencing a previous trauma. The provider knew this but removed the carpet and installed new vinyl flooring in the home anyway, leaving them feeling very anxious and reluctant to leave their room.
“We heard one person had been prescribed anti-psychotic medicine for a number of years. A health professional was concerned about their health as a result of receiving the medicine. When they asked about it, they were told the person rarely showed behaviour which the medicine had originally been prescribed for. The health professional asked why the medicine hadn’t been reviewed, and the staff member told them, "If it ain't broke don't fix it."
“We have told the provider to make urgent improvements to ensure that people and staff are safe, and we will monitor the service closely to ensure these are made and fully embedded. If they are not, we will not hesitate to take further enforcement action.”
Inspectors found the following during this inspection:
- There was a lack of management and provider oversight of the service. The registered manager had been absent, and for the most part working remotely, since April 2020. The provider was not aware the registered manager had been absent from the service for this length of time
- Staff were not always kind and respectful towards people and people were not protected from abuse from staff. The registered manager and provider had failed to investigate concerns relating to people being abused at the service. This was despite evidence that indicated a poor staff culture
- People were not being supported to lead meaningful and empowered lives. The provider did not focus on people's quality of life, and care delivery was not person centred. Staff did not recognise how to promote people's rights, choice or independence. The ethos, attitudes and behaviours of managers and staff did not ensure that people could lead confident, inclusive and empowered lives
- There was limited meaningful activity offered to people and there were long periods of time where people had no engagement with staff. Although relatives accepted activities had reduced at the start of the COVID-19 pandemic, this continued when the restrictions relaxed, and relatives said this had negatively impacted their loved ones
- There were not sufficiently trained or supervised staff to safely meet the needs of people. There were people at the service who had needs relating to autism, learning disabilities, epilepsy, mental health and diabetes, but some agency staff had not any training in these areas. They also had not received training in positive behaviour support
- Risks to people were not were not always appropriately assessed or measures taken to enable people to live safely in their home. This included risk of choking, and risks associated with epilepsy and pressure sores
- Medicines were not always managed safely. Some medicine, which was needed for a person in the event of an epileptic seizure, was out of date. Some people were prescribed 'as and when' medicine for particular behaviours, but there was no guidance in place for staff to advise when this needed to be administered
- Advice from health care professionals was not always being sought in relation to people's care. One person experienced unaccounted weight loss over nine months. It was recognised they were at high risk of malnutrition, yet no action was taken to address this. Another person had urinary incontinence for 12 months, yet staff had not sought professional help to identify the cause. One person who needed hearing aids had lost them, but no action was taken to replace them, and the person’s verbal communication decreased
- Staff decided what people would eat and only served them small portions, yet staff piled their own plates with food at mealtimes. People were not allowed to help themselves to drinks, but some staff appeared cross when people asked for drinks
- Staff did not always communicate with people in ways they understood
- Behaviours and incidents were not always recorded and analysed to look for trends. This meant there was little opportunity for lessons to be learned when things went wrong
- Complaints were not always recorded and responded to appropriately.
Full details of the inspection are given in the report published on our website.
Notes to editors
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