The Care Quality Commission (CQC) has rated Head Office, part of Mitchell's Care Homes Limited inadequate and placed it into special measures to protect people following an inspection in May.
Head Office is a supported living service providing care to autistic people and people with a learning disability. Some people also have physical disabilities and a mental health diagnosis. Support was provided across twenty-one different supported living settings where people had their own houses or rooms. As part of the inspection, CQC visited eleven of the supported living homes.
CQC carried out this unannounced comprehensive inspection due to concerns received about people not being protected from abuse as well as unsafe care and staffing levels.
Following the inspection, the overall rating for the service has dropped from good to inadequate, as did the ratings for safe, effective, caring and well-led. Responsive has declined from outstanding to inadequate.
Head Office being placed into special measures means CQC is closely monitoring it, and it will be inspected again to assess whether improvements have been made.
CQC have also taken further enforcement action to protect people and will report on this when legally able to do so.
Rebecca Bauers, CQC’s director for people with a learning disability and autistic people, said:
“Mitchell's Care Homes Limited wasn’t providing a culture for people who called Head Office home should be able to expect nor were they protecting the vulnerable people in its care.
“It was unacceptable that people experienced physical and verbal abuse by other people living with them. This included people telling us they were being bullied and were involved in physical altercations such as having their food and drinks grabbed from them when they were eating it. We saw a culture where Head Office staff were taking little action to address this, to ensure that people felt safe in their own home. This forced people into taking their own evasive action to protect themselves such as staying in their room when they would prefer to sit downstairs in the common areas. They must address this urgently as a matter of priority.
“We saw staff inappropriately restraining people which infringes on their human rights. One person in a heightened state of anxiety was restrained by a member of staff who held their arm with one hand and had another around their waist. There was no guidance in this person’s care plan around staff using restraint in this way.
“If someone was running away from the home, the provider’s guidance was to catch and stop them, but staff weren’t clear on what this meant. This meant people were being physically restrained by staff without the appropriate training, authority, or consent to do so, putting people at risk of harm and trauma.
“The provider has also failed to ensure good staffing levels, which was putting unacceptable pressure on staff to not take breaks to ensure people’s safety. At one of the homes, where staff supported someone 24 hours a day, there was nobody to cover staff breaks, leaving the person using the service at risk. Staff told us they were fatigued because they were choosing to not have a break, so the person wasn’t left alone.
“We will return to check on the progress of improvements we’ve told them to make and are now in the process of taking further regulatory action, which we’ll report on when we’re able to. In the meantime, we will be closely monitoring this service along with the local authority and the integrated care board, to ensure people’s safety.”
Inspectors found:
- The provider had failed to provide the right training to staff for people that were at a heightened state of anxiety. One person had managed to leave their home and enter a neighbouring home and destroy furniture putting others at risk
- People weren’t protected from the risk of financial abuse
- Staff were recording incidents of distress, but this information wasn’t being evaluated to identify possible triggers to avoid any anxiety
- Medicines weren’t being managed in a safe way, which placed people at risk of harm
- People weren’t being helped or supported to access the health care services they needed. Relatives weren’t always confident that staff were supporting their loved ones with health appointments
- The provider had failed to ensure suitably qualified and skilled staff were employed to meet people’s needs. Even relatives felt staff weren’t appropriately trained.