Thread by @GeorgeJulian

I’ve been reporting from Robert Chaplin’s inquest this week so am behind on newly published @carequalitycomm reports into learning disability and/or autism care

First up @ConsensusLD Smugglers Barn, which inspectors decided requires improvement api.cqc.org.uk/public/v1/repo…

1/25+

The date on the report is 5 July but the date published on the CQC website is 13 July, and the inspection took place in February.

That seems like a long time between inspection and findings. Maybe something, maybe nothing.

2/

So that do we know about Smugglers Barn? And @ConsensusLD, well a little snippet from their website:

Our strong governance systems and processes give safety and security to the people we support and allow us to manage risk effectively.

3/

There's more:

Our commitment to delivering the highest standards of support is nationally recognised and validated by the many awards we receive, the consistently high ratings we receive from national regulators

Let's dig deeper shall we... consistently high ratings?

4/

Smugglers Barn is a residential care home providing personal care to 9ppl at the time of inspection.

The home is comprised of two separate houses in close proximity, Smugglers Barn and Little Smugglers, these are both under the same registration with @CareQualityComm

5/

Risks to people's health had not always been properly assessed to ensure they remained safe.

Staffing levels were inconsistent and not always sufficient to meet people's needs.

People's positive behaviour support was not always adequately managed.

6/

People were not always supported with meaningful occupation and activities.

Some people were supported to follow interests close to them and measures were in place to encourage people to access the community, although many were unoccupied and lacked structured routines.

7/

We have made a recommendation about the organisation of activities for people at the home.

Feedback about the management of the service was mixed.

Staff and relatives said that communication was poor and lacked a willingness to work together.

8/

One staff member said, "We have not had consistent leadership."

Quality assurance systems were in place but had not always identified issues that were found at the inspection.

[So there aint really much point them being in place then is there]

9/

Based on our review of Safe, Responsive and Well-led, the service was not able to demonstrate how they were meeting some of the underpinning principles of Right support, right care, right culture

10/

Some people's needs had not always been properly assessed to ensure they were protected from avoidable harm.

The model of care and setting did not maximise people's choice, control and independence.

11/

People were not receiving person-centred care due to the systems in place and staffing issues.

Some people's specific support needs were not always clearly identified and met.

12/

People's needs and preferences were known by caring staff, but consistent shortfalls in staffing levels meant that people did not always have access to meaningful occupation or receive the amount of support according to their assessed need.

13/

[Not much point people's needs and preference being known by people who aren't caring for them. So much performance]

People did not receive planned and coordinated person-centred support that was appropriate and inclusive for them.

14/

Leaders were not always transparent and did not promote an open culture at the service.

We received concerns in relation to an increase in safeguarding issues, management of peoples distressed behaviours and the governance of the service.

15/

As a result, we undertook a focused inspection to review the key questions of Safe, Responsive and Well-led.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

16/

The overall rating for the service has changed from good to requires improvement based on the findings of this inspection. We have found evidence that the provider needs to make improvements.

17/

Some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

Risks to some people's care was not always monitored and managed safely.

18/

For example, one person had previously been observed by staff as having seizure activity in April and May 2021.

Staff had made appropriate referrals for support, although documentation showed that an epilepsy diagnosis was still being investigated.

19/

There was no care plan or risk assessment to guide staff with any potential subsequent seizure activity.

There was no advice on how to support that person safely and effectively, should they experience any further seizure activity.

20/

One relative said, "I don't think they (staff) fully understand his epilepsy. There are various types of seizure. The one that he has is absences - he has a lot of those. Last year one staff member said he doesn't have many at the service, but he does at home..."

21/

"...but I don't think they recognise them. The staff should be more aware about these things."

Other risks had been identified but not appropriately monitored or managed.

One person had been identified as being at risk of choking.

22/

There was no record of an appropriate Speech and Language Therapy (SaLT) assessment or that a referral had been made.

Although staff had been instructed to cut the persons food up, the failure to seek specialist support meant that choking risks to the person remained.

23/

The operations manager stated on the second day of the inspection that staff had made contact with the person's GP to request a referral to the SaLT team.

24/

The provider has failed to do all that was reasonably practical to mitigate the risks people's health and safety. This was a breach of regulation 12 (Safe Care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

25/

There were not always sufficient levels of staff to meet people's needs.

Feedback from staff and relatives was poor regarding the level of support people received due to staffing.

26/

One staff member said

"When I started, we never used agency and had enough staff. Three months after, staff started leaving one after another. We felt the effect. We started getting agency in. There were different faces every day, three times a day"

27/

"We do get regulars now and the guys are getting used to them. The weekends are the worst though. It can go from one end to the other."

The lack of permanent staff and consistent staff numbers had impacted on staff's ability to effectively support some people.

28/

One staff member said:

"The only concern is about the staffing, they (people) are being limited in what they can do.

This has been a big challenge.

They have hours of 1:1 which most of the time they don't get"

29/

"If there's two on shift and there should be three staff it doesn't work out.

Those people need support with 1:1 which is sometimes not possible.

(The manager) has failed us and we have raised our concerns and nothing has been done about staffing and other issues."

30/

Another staff member said, "We are short staffed here now. Sometimes you get days where it gets on top of you. There is so much pressure with staff."

One relative said, "I think they are having staffing problems at the moment. I don't know what they are doing about it."

31/

We looked at eight weeks of staff schedules. The acting manager stated that schedules were in the process of being transitioned from separate rotas for each house in Smugglers Barn to a combined schedule for consistency.

32/

Rotas showed that there were often fewer staff than planned on many weekends.

The service used agency staff frequently to address shortfalls in permanent staff members.

33/

The provider had not ensured that sufficient numbers of suitable, experienced staff were deployed to meet people's needs.

This was a breach of regulation 18 (Staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

34/

Systems were in place to protect people from the risk of abuse, although these were not always effective.

Some people displayed distressed behaviours and were a risk to themselves and others without the presence and intervention of staff.

35/

Staff told us that they received Positive Behaviour Support (PBS) training to support people when they were distressed or agitated, but some staff said that challenges with staffing meant that people were not always effectively supported.

36/

Another staff member said

"At Smugglers Barn its acted on well and they are supported properly. The challenge is at Little Smugglers. There are a lot of incidents and challenges. Most of the staff resigned and they end up in a situation where they can't manage them well"

37/

"They are very vulnerable and need 1:1. They got some injuries in the process."

One professional said, "There appears to be a real lack of understanding of [person] needs as a person with severe learning disability and autism by the service."

[21st Century Care eh]

38/

The registered manager did not always effectively manage safeguarding concerns when they were raised.

Concerns were raised on how one investigation into potential abuse was managed and how information was shared.

39/

One professional said about the highlighted concern

"It took the service over four months to share the summary of their internal safeguarding investigation report, which the family felt was incomplete and did not fully explain the investigation process or outcomes"

40/

"There did not seem to be a robust policy in place about how internal investigation outcomes linked to safeguarding concerns were disseminated to all relevant parties."

[Not to mention how much ongoing exposure to risk during that period]

41/

We asked one staff member how new staff or agency staff were given guidance about care needs and how to support distressed behaviour, but the staff member was unclear about how this was done.

42/

One staff member said, "PBS plans are effective. At the moment we are really short staff and we have agency staff. Permanent staff who knew them have left. It's a big challenge and most of the time they change staff and people can't get used to them"

43/

"Every day they see new faces. It takes time for people to get used to them and for them to get used to. They might not get time to read support files. This is where the problem sometimes comes from."

44/

[Do we need the magic PBS bullet, or do people just need consistency and respect. Either way sounds like they’re not getting it in this service]

45/

At the last inspection this key question [responsive] was rated as good. At this inspection this key question has now changed to requires improvement. This meant people's needs were not always met.

46/

People, staff and relatives told us that while some people's interests and activities were supported and facilitated by staff, there was a lack of emphasis on providing occupation and activities at the home.

47/

The manager explained that the Covid 19 lockdown had had an impact on people's confidence to go out in the community.

However, our observations during the inspection was that there was limited organised occupation for people within the service.

48/

One staff member said "We encourage them to get out. Part of it is the lack of staff, we can't do much. The only activities they would really do is get up and go out."

[Them. Just for the record getting up and going out to aimlessly walk around, is not an activity]

49/

Staff and peoples loved ones told us that while Covid had an impact on some, the issue with staffing was now impacting on their ability to provide meaningful occupation and access to the community.

50/

Relative told us, "They definitely don't put any activities on. They blame Covid. They have big area there. There's nothing stopping staff supporting people outside and there's no activities inside either."

[People see thru the excuses, and get ignored]

51/

Relative commented

"No I don't think they keep him occupied. He spends most of the time in his room watching DVDS. There's not much routine, not like when he first went there when they had a proper programme. They don't do much in the way of activities"

52/

"He looks forward to his visits home here"

One person said: "We are low on staff at the moment, we are short. You can't do so many activities it does affect this. They are trying."

[The generosity of people who need support, and are being denied a meaningful life]

53/

The provider had not ensured that sufficient numbers of suitable, experienced staff were deployed to meet people's needs.

This was a breach of regulation 18 (Staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

54/

Feedback from relatives was mixed on how the registered manager dealt with any issues or complaints they raised.

One family member said "I did have to make a complaint with the previous manager and it wasn't addressed and went to her line manager as I didn't feel it was..."

55/

"...being dealt with. When I've raised things with (current registered manager) which happens from time to time, she is very good at dealing with them and keeping me informed."

56/

At the last inspection this key question was rated as good. At this inspection this key question [well-led] has now changed to requires improvement. This meant the service management and leadership was inconsistent.

57/

Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

Service had a registered manager who was not working at time of inspection. Day-to-day oversight of the home was being undertaken by a peripatetic manager

58/

People and staff all spoke of an inconsistency in leadership, stating that improvements in management support and communication were needed.

One person said, "Management is ok, could be better."

59/

One staff member told us, "We do a lot for the management to get things resolved. The provider could do more. They could listen to us. I haven't had an incident or problem at work, but other people have. We talk to each other"

60/

"The things I've heard that management haven't done. It would be nice to be filled in with what is happening rather than keep us waiting."

Another staff member said

"The permanent staff numbers are low. They left because of the management".

61/

"...If you don't communicate with staff when there is a problem or concern or listens to what staff are saying, this will cause a problem.

Staff don't see themselves as valued."

62/

Staff spoke of the lack of communication around people's needs and getting response and feedback to issues they had raised.

[We hear so much about the shortage of staff in social care, maybe part of the conversation should switch to the poor management in #socialcare]

63/

Staff said

"We are the frontline, but I'd appreciate for the people there we are supporting, we don't really get listened to. I just feel like they don't really listen. Management sit in their office, busy, but not listening."

[Frontline = war. Management performance]

64/

Altho the provider has quality assurance systems in place, they were not always successful in identifying the issues raised in this inspection.

[That's because they're performative, they're there to show that they're there, not to usefully use them]

65/

Audits altho completed regularly, had not identified issues or changes required and no actions had been taken forward to show learning and ongoing improvement.

66/

One professional commented on the registered manager's failure to effectively monitor and review essential guidance for one person's behavioural support.

They said, "Sensory support strategies are integral to their ability to self-manage and a missing document..."

67/

"... with essential information stating daily support strategies should have been picked up by the manager months before their behaviour started to deteriorate.

This flags up the fact that his PBS plan was not adhered to or reviewed by the manager and the staff..."

68/

"... and instead (the person) was supported using ad-hoc strategies, which did not always lead to favourable outcomes."

[PBS plans aint worth the paper they're written on. No plans are if they're done to be seen to be done. Not followed]

69/

Staff were positive about the care they provided to people but indicated that their roles required support and clarity from management to undertake them successfully.

70/

One staff member said, "To me the management has been poor. In areas of coordination between support workers and the management, there's hasn't been a good relationship. If that's not there, then a lot of things don't work. People can't be open"

[This is dangerous]

71/

"Communication of information about support we are to give is passed on well, but if there's a concern you want management to iron out, you may not get a good response."

72/

Although the provider was aware of their responsibilities around duty of candour, we received concerns from some relatives that the registered manager had not always been forthcoming and open when communicating with them when things went wrong.

73/

[This is precisely why all the calls for training in the world aren't gonna improve people's lives.... they've done Duty of Candour training, they can reel off their responsibilities... and it makes naff all difference, because they're not embodying it]

74/

Relative said of the registered manager

"She just sweeps things under the carpet, but they have a new deputy manager and they are trying their best."

Provider had not ensured effective systems were in place to monitor and improve quality and safety of services provided

75/

There were not effective communication systems in place to ensure that people who use the service, those who need to know within the service and, where appropriate, those external to the service, know the results of reviews about the quality and safety...

76/

..of the service and any actions required following the review.

This was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

77/

Management had ensured they informed CQC of any significant events, such as when there had been suspected abuse or when someone had suffered a significant injury. This ensured CQC could monitor that the correct actions had been taken.

[Suspected abuse. Significant injuries]

78/

So @ConsensusLD have to tell @CareQualityComm how they're going to take action to improve things, and CQC will monitor to check they do.

Time will tell I guess. Let's hope for no possible abuse, or significant injuries, in the meantime.

/END