The Care Quality Commission (CQC) has rated Forge House Services Limited in Cullompton, Devon, inadequate overall, following an inspection in August and September.
Forge House Services Limited is a residential care home providing accommodation and personal care for up to 11 people who may be living with a learning disability or autistic people.
Following the inspection, the overall rating for the service has dropped from good to inadequate. The ratings for being safe, effective and well-led have also dropped from good to inadequate. While the ratings for caring and responsive have dropped from good to requires improvement.
The service is now in special measures which means it will be kept under review, by CQC and re-inspected to check sufficient improvements have been made.
Debbie Ivanova, CQC’s director for people with a learning disability and autistic people, said:
“During our inspection of Forge House Services Limited we were concerned to find widespread and significant shortfalls in the service. Staff weren’t always clear about their roles and responsibilities in delivering high quality care..
“We found indications of a closed culture within the service, meaning people did not have full lives in the service and their involvement in making choices about both their care and their ambitions was very limited This included a lack of involvement from other professionals, no specific training to work with autistic people and people with a learning disability, and safeguarding incidents were not reported. Restrictive practices were frequently used and there was a poor application and understanding of the Mental Capacity Act (MCA) including not following the MCA codes of practice, which needs to be addressed immediately.
“The systems in place didn’t help people to be safeguarded against discrimination, harm and abuse. Records didn’t give a clear picture of incidents, triggers, or any other metrics that staff and leaders could use to learn from to improve the service.
We also found that incidents weren’t reported externally in an open and honest manner when things went wrong. Some people had been physically hurt and had unexplained bruising, which hadn’t been reported. This lack of reporting, and investigation meant people were at risk of recurring harm.
“We have told the provider to make urgent improvements to ensure that people are safe, and will monitor the service closely to ensure these are made and fully embedded. We will not hesitate to take further enforcement action to drive the improvements needed.”
Inspectors found the following during this inspection:
Safeguarding incidents were not always reported to the local authority. Inspectors saw records where a person had choked due to staff not following their choking risk assessment. Although this had been reported to the registered manager, and a review by a speech and language therapist requested, no further investigation had taken place to understand why the incident had happened.
People weren’t leading inclusive and empowered lives because staff didn’t place people's needs and rights at the heart of everything they did. There was a lack of information about people’s preferences and they were not always involved in planning their care.
Some people in the home could harm themselves or others when they were distressed. Staff were not trained to use physical interventions, using the safest and least restrictive methods, as outlined in people's support plans. This meant the provider failed to ensure staff knew how to safely support people.
People's consent to care had not been sought appropriately. There was no record that anyone had been asked to consent to their care plan. One person had a physical intervention plan in place that included restraint. It was not clear who had been involved in agreeing this restraint. While inspectors had been told the person had capacity and had consented to this themselves, the space for the person's signature on the plan was not completed.
People were found to be deprived of their liberty without the legal authority. The Deprivation of Liberty referrals made did not detail all the restrictions that inspectors found in place.