The Care Quality Commission (CQC) has rated The Pleasance in Doncaster, inadequate and placed it in special measures following an inspection in December.
This unannounced inspection was prompted by a review of the information held about this service since the last inspection.
The Pleasance is a care home that provides accommodation and personal care to people with learning disabilities, autism and mental health needs. At the time of inspection 12 people were supported by the service.
Following this inspection, the care home’s overall rating has dropped from good to inadequate. Ratings for how safe the home is have dropped from good to inadequate, and how well-led the service is has dropped from requires improvement to inadequate. Ratings for effective, caring and responsive were not inspected and remain rated as good.
The service is now in special measures which means it will be kept under review by CQC and re-inspected to check on the progress of improvements.
Debbie Ivanova, CQC’s director for people with a learning disability and autistic people, said:
“It's unacceptable that the care being delivered by The Pleasance, wasn’t of the standard that people should be able to expect. It was disappointing that the standard of care had deteriorated significantly since our last inspection.
“Previously, we rated well-led as requires improvement and told the service it needed to improve. Yet, during this inspection we noted leadership still hadn’t taken all the necessary action to make sure services were safe.
“People were at significant risk of harm as known risks had not been adequately assessed and reduced. For example, during our last inspection, we told leadership to put plans in place to reduce the risks people living with epilepsy faced at night-time, yet during this inspection, this still hadn’t been addressed and people were still at risk.
“We saw people left alone in communal areas without the necessary support, so staff could carry out other duties. On one occasion, someone had been left unsupported and they choked on food. There was an investigation carried out by the provider and appropriate action agreed to reduce further risks. Despite this, we found other examples where people were left unsupported placing them at risk of harm.
“Additionally, some areas of the home were in need of a deep clean, and some flooring needed replacing as it posed an infection hazard.
“Accidents and incidents were not effectively recorded and analysed by staff. Some safeguarding incidents had also not been reported to the police or local authority.
“As the service has been rated inadequate and placed in special measures, we’ll continue to monitor it closely to ensure people are safe. If we aren't assured people are receiving safe care, we will not hesitate to take further action.”
Inspectors found:
- The manager hadn’t reported incidents to the police, safeguarding or the local authority, or submitted notifications about incidents as required by law to CQC.
- The provider had failed to put robust systems in place to assess, monitor and improve the quality of services. This put people at risk of harm and avoidable abuse.
- The provider had failed to make sure the premises and people’s belongings were secured.