The Care Quality Commission (CQC) has rated Boulevard House in Mablethorpe, Lincolnshire, inadequate and placed it in special measures following an inspection in November.
Boulevard House is a residential care home providing accommodation and personal care for up to 15 people with a learning disability. At the time of our inspection there were 12 people using the service.
This unannounced focused inspection was prompted by a review of the information we held about this service.
Following this inspection, breaches were found in relation to person-centred care, consent, safe care and treatment, safeguarding people from abuse and improper treatment, good governance and staffing.
The home’s overall rating has now dropped from good to inadequate. It has also dropped from good to inadequate for being safe, effective and well-led. Responsive and caring were not included in this inspection 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 sufficient improvements have been made.
Debbie Ivanova, CQC’s director for people with a learning disability and autistic people, said:
“When we inspected Boulevard House, it was concerning that we found a closed culture, which the provider hadn’t taken action to identify or address which put people at risk of harm.
“Language used in care plans and incident reports showed it also had an oppressive culture. For example, a care plan stated, that someone was aware of the house rules within Boulevard House and generally abides by them.
“We also observed inequality as a staff member drank in the lounge however, people living at the home were told they couldn't in case of spillages. This controlling behaviour is totally unacceptable and vulnerable people using this service should expect to be treated with more dignity and respect.
“Physical intervention was used by staff who hadn’t received the necessary training by a certified training provider. Additionally, incident forms didn’t contain enough information to explain what had happened and what physical interventions staff had used on people. Therefore, it wasn’t clear if physical interventions were safe or justified for people using the service.
“We will continue to monitor Boulevard House closely to ensure people are receiving the safe care they deserve. If we are not assured this is happening, we will not hesitate to take further action in line with our regulatory powers.”
Inspectors found:
- People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice
- One person's wardrobes were locked without consent. The provider had not completed a mental capacity assessment or carried out a best interest meeting to evidence locking the wardrobe was in the person's best interests
- There were no protocols for 'as required' (PRN) medicines which were used to manage distress. When PRN medicines were given to people, records were not thorough or detailed. There was no evidence of post incident analysis or review of PRN medicines when they had been used to support people in distress
- Lessons were not learnt, and improvements were not made when things went wrong. Staff did not learn from incidents to ensure people had better experiences and positive outcomes
- Risks were not identified or assessed which put people at risk of harm
- Governance systems were ineffective as they failed to ensure regulatory requirements were met.