A care home in Merton, south London has been rated inadequate by the Care Quality Commission (CQC) and placed in special measures, following an inspection in July.
Rosebank Lodge in Mitcham, which provides care to people with a learning disability and autistic people, was previously rated as good.
The inspection was carried out to follow up on concerns shared with CQC about the care being provided to people.
It found that people were being unlawfully locked in their bedrooms and that unlawful restraint was being used by staff.
Following our inspection, the service was rated inadequate overall with a rating of inadequate for being safe and well-led. The key questions of whether care at Rosebank Lodge was effective, caring and responsive to people’s needs weren’t assessed on this occasion.
Rosebank Lodge has breached regulations and CQC has placed it in special measures and told the service what action it must take to improve and meet its legal requirements. It will be kept under close review but, if swift and significant improvements aren’t made, further action will be taken, which could include closing the service, to keep people safe.
James Frewin, CQC head of adult social care inspection, said:
“We carried out an unannounced inspection of Rosebank Lodge to follow up on concerns that people were being unlawfully deprived of their liberty.
“It was unacceptable to find that restrictive practices were being used without the necessary legal authorisation.
“People were locked in their bedrooms, their water supply was cut off and inspectors saw one person being unlawfully restrained by staff.
“People’s rights were clearly not being respected and the service had a closed culture where people weren’t supported to live freely from unwarranted restrictions.
“The service has breached regulations relating to consent, safeguarding, improper treatment and good governance, but we have been assured by management that door locks have now been removed and people are able to move freely around their home.
“We have told the service what it must do to improve but will not hesitate to take further action, which could mean closing the care home, if we don’t see immediate and far-reaching improvement to protect people from harm.”
The inspection found that people living at Rosebank Lodge didn’t have maximum control over their lives. Staff didn’t do everything they could to avoid restraining people, and incidents weren’t recorded. This meant that staff didn’t learn how similar situations could be avoided and de-escalated in the future.
As well as unlawful restrictions being placed on people, other risks were identified by CQC inspectors. Incidents of injury to people weren’t recorded properly or reported to CQC, and the lack of risk assessments meant people could be receiving unsafe care. For example, there was no clear guidance in place about how staff should respond safely to one person who was at particular risk of choking.
Medication wasn’t always managed safely so people were at risk of receiving the wrong medicine or dose, or sometimes didn’t receive it at all.
All these issues were underpinned by a lack of effective leadership and oversight at the service. Managers weren’t always aware of problems within the service and didn’t ensure the delivery of high-quality care, failing to consistently work with healthcare professionals and implement their guidance to improve the care provided to people.
However, there were enough staff to provide care and support to people and people could participate in activities both at home and in the local community.
The area manager had also taken action to address the concerns raised by the inspections.