Thread by @GeorgeJulian

Morning tweeps, I'll be honest, I spotted this report yday and ran out of time/energy/soul to cover it.

This is a report into a care home for learning disabled and autistic people 1.3miles from my house.

Its rated inadequate and I dread what we'll find in this report

1/25+

Full report is here api.cqc.org.uk/public/v1/repo…

Everything that follows will be quotes from the report, I may remove the odd word to fit into a tweet, but it wont alter the meaning.

[I'll add my commentary, thoughts, despair in square brackets throughout]

2/

Burlington Care and Support Services, referred to as Burlington House, is a residential care home that provides personal care and support for up to 13 people with a learning disability.

At the time of the inspection there were 10 people living at the service.

3/

Accommodation is provided over two floors within two separate but adjoining buildings.

People told us they felt safe, they liked living at Burlington House and most relatives we spoke with did not raise any concerns about the care their loved ones received.

[Most relatives]

4/

[I'm gonna put it out there, it's essential that @CareQualityComm gather evidence via feedback from relatives.

However, that in itself is limited by what relatives see/hear/know.

They may not know how bad a service is. They may also think anything is better than nothing]

5/

We found the service was not operating in accordance with the regulation and was not able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture and best practice guidance.

6/

People were at risk of not receiving care and support that promoted their wellbeing and protected them from harm.

People were not always supported to have maximum choice and control of their lives

7/

Staff were not supporting ppl in least restrictive way possible and in their best interests.

People were not involved in a meaningful way in development of their care and support and info was not always provided in a way which met people's individual communication needs

8/

Care was not always provided in a person-centred way which promoted people's dignity, privacy or human rights.

People's care and support plans were not always reflective of their range of needs, supported their aspirations, or promoted their wellbeing and enjoyment of life.

9/

The ethos, values and attitudes of managers did not always ensure people using the services were enabled to lead confident, inclusive and empowered lives.

10/

Staff understood their role in making sure that people were always put first, but care and support was not always tailored to their individual needs and preferences.

11/

The last rating for this service was requires improvement (published 14 December 2019). Following that inspection, the provider was asked to complete an action plan to show what they would do and by when the improvements would be made.

12/

At this inspection we found the provider remained in breach of regulations and has been rated requires improvement for the last four consecutive inspections.

[In breach 2yrs 6mths later - why were they allowed to be in breach for so long?

People's lives passing them by]

13/

Overall rating for service is 'Inadequate' and service is therefore in 'special measures'.

We will keep the service under review and, if we do not propose to cancel the provider's registration, we will re-inspect within 6 months to check for significant improvements.

14/

If the provider has not made enough improvement within this timeframe.

And there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures.

15/

This will mean we will begin the process of preventing the provider from operating this service.

This will usually lead to cancellation of their registration or to varying the conditions the registration.

16/

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months.

[Let's dig a little deeper to see what the lie of the land here is cqc.org.uk/location/1-126…]

17/

[There are @CareQualityComm records back to 2009 for this place.

Feb 2009 there were three recommendations made - around medication management, environment and quality management/governance systems]

cqc.org.uk/_dp/files/1ec9…

18/

[Feb 2010 CQC did a paper based exercise and decided nothing had changed cqc.org.uk/_dp/files/1ec9…

Oct 2012 - new inspection approach - three visits in August. Report here cqc.org.uk/_dp/files/1ec9…

Some snippets follow]

19/

One person told us they very much liked living at Burlington house, altho they had not liked it when they first came. They told us the staff were very kind and were helping them for the essential standards of quality and safety to move forward into supported living - Oct2012

20/

Other people told us "I like my room. I like peace and quiet. They (staff) don't come up here very often, and I can do what I like"

People we spoke with told us about the staff. One person told us "Some of them are nice, some not as nice. But I don't mind them all really".

21/

People were not being protected against the risks associated with medicines because the provider did not have appropriate arrangements in place to manage medicines.

The provider was not meeting this standard.

22/

We judged that this had a minor impact on people using the service and action was needed for this essential standard.

[So they weren't meeting standards around medicine management 10 years ago, wonder whether they've sorted that by now]

23/

People were not being protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were not being maintained.

The provider was not meeting this standard.

24/

We judged that this had a minor impact on people using the service and action was needed for this essential standard.

[So, 10 years ago, they were also failing to meet standards around record keeping - let's see if things improved in the years that followed]

25/

[In 2012, Burlington Care and Support had to send @CareQualityComm a report saying what actions they'd take to improve things.

I've a nasty feeling we might hear that a lot. Let's see what their next inspection found]

26/

[April 2013 an inspector popped around and found they met all standards, despite still having concerns cqc.org.uk/_dp/files/1ec9…]

When we last inspected Burlington House in August 2012 we had some concerns over the record keeping, care plans and medication management systems.

27/

Home sent us a plan telling us what they intended to do to put things right. On this visit we looked at action they had taken.

We found that the home had implemented the changes needed, but some areas of record keeping, policies and procedures still needed to be improved.

28/

[The following year @CareQualityComm inspected again, in May this time, reported in June 2014 cqc.org.uk/_dp/files/1ec9…

They found action was needed - the same thing they found in Feb 2009, 5 years previously]

29/

[June 2014, 5yrs after stair carpets needed attention, decor still needed work]

Registered Manger explained home needed physical work doing to it. They planned for this to be completed in the near future. We could see that the home's decor and furnishings were quite dated.

30/

[Dec 2016 @CareQualityComm visited again, report published in Feb 2017 api.cqc.org.uk/public/v1/repo… and now the overall rating is Requires Improvement.

Let's see what they found on this occasion. Hats off to CQC for transparency and all this being available btw]

31/

Burlington House was previously inspected in May 2014, when we found the provider did not have effective systems to identify, assess and manage risks to the health, safety and welfare of people or to regularly assess and monitor the quality of service provided.

32/

At this inspection, we found that although some improvements had been made further improvements were needed.

The registered provider is also the registered manager.

[So are the concerns from 2009 still outstanding in 2017? Have a guess]

33/

Following our last inspection, the provider had introduced a new quality auditing system. We found this had introduced some improvements but was not fully effective to assess and monitor the quality and safety of the services provided at the home.

37/

Although some systems were working well, risks to people's health and wellbeing had not always been identified, assessed or mitigated.

People's individual needs were not always assessed or planned for.

[What's the point then?]

38/

Whilst support plans and risk assessments reviews were taking place monthly, these had not identified the lack of information or instruction for staff in how to meet people's needs.

[Not worth the paper they're written on. Performative audit because they've been told to]

39/

Where people had specific needs relating to their behaviour or lifestyle choices, risk assessments did not identify the risk of potential harm to other people living at the home, the person, or contain guidance for staff on how to manage these risks.

40/

We have made a recommendation that the provider keep the system for identifying risk and mitigating risk under review.

[Honestly. How can this be recommended?

8 years after @CareQualityComm inspector first flagged it. 8yrs, in a 'home for life' as it was called in report]

41/

Registered manager had not always notified the Care Quality Commission of significant events, which had occurred in line with their legal responsibilities;

this included the notification of safeguarding concerns.

[My heart is sunk, and we're only on the previous reports]

42/

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

[It's reproduced here. This was Feb 2017]

43/

[Back to now. July 2022. What did they find?]

The registered provider is also the manager. This means that they are legally responsible for how the service is run and for the quality and safety of the care provided.

44/

The inspection took place on the 28 April, 05 and 10 May 2022, the first day was unannounced.

[Safe - inadequate]

Last inspection we rated this key question good. At this inspection rating has changed to inadequate.

People were not safe and were at risk of avoidable harm

45/

Although some relatives told us they felt people were safe, our findings were that people were not safe as the provider had failed to take adequate steps to address concerns relating to the management and mitigation of risks.

46/

This meant service users, staff and others were exposed to the risk of avoidable harm.

People were placed at risk of avoidable harm as staff did not have all the information they needed to meet people's needs safely.

47/

One person had been admitted to the service in September 2021.

This person did not have a pre-admission assessment, care plan or any assessment of risks associated with providing care and support.

48/

This potentially placed this person, staff and others at an increased risk of avoidable harm.

Another person had been admitted to the service in August 2021.

[Where are the commissioners? Social workers? Why is no-one checking up on this in real time @Torbay_Council?]

49/

Staff said they did not have access to a care plan and were not provided with any guidance on how they should meet this person's support needs until April 2022 when a support plan was created.

Senior managers told us the delay had been due to covering shifts.

50/

We found care records for this person indicated potential risks, none of which had been fully assessed or form part of this person's risk management plan and staff had not been provided with any guidance on how they should manage or mitigate these risks.

51/

Where risks had been identified, the provider could not demonstrate that enough action had been taken to mitigate those risks and keep people safe.

One person had been assessed at risk of falling, due to a history of falls.

52/

Staff were instructed to provide supervision when going up and down stairs.

During the inspection we observed this person walking up and down the main staircase.

At the time of the observation this person did not have one to one support or supervision from staff.

53/

The failure to ensure that staff followed the guidance written in the persons care plan exposed this person to the risk of avoidable harm.

[Wonder if the Feb 2009 action to replace stair carpets ever happened too]

54/

One person's pre-admission assessment highlighted that this person could at times of emotional distress present a risk of harm to themselves as well as others.

55/

This information did not form part of this person's care plan and there was no risk assessment in place to guide staff as to any actions they should take to keep this person, themselves and others safe.

56/

Failure to assess and mitigate these risks placed this person, staff and others at an increased risk of avoidable harm.

One person's referral record identified they had been diagnosed with Epilepsy, altho they had not experienced a recent seizure.

[We know what's coming]

57/

There was no care plan or risk assessment in place regarding the management of this person's Epilepsy or seizure activity.

Staff had not been provided with any guidance on how they should manage or mitigate these risks.

[Epilepsy. People die without the right support]

58/

When we asked, one of the managers told us they did not know this person had been diagnosed with Epilepsy.

[How? How did they not know? They were being paid to provide care to this person. How can they not know something as fundamental as the fact they have epilepsy?]

59/

[There are other ongoing risks too]

Provider failed to ensure people were protected from risks associated with their living environment and fire safety systems.

We reviewed the services fire risk assessment and found this had not been reviewed or updated since August 2019

60/

Where risks had been identified by staff, action had not always been taken to minimise or mitigate those risks and keep people safe.

In December 2021, a staff member identified the need for a window restrictor to be fitted to one person's window.

61/

At the time of this inspection five months later no action had been taken and the risk was still present.

We discussed what we found with the provider who told us they had not been made aware of the risk and assured us this would be addressed.

[How did they not know?]

62/

People told us they felt safe and relatives were confident their loved ones were safe.

A relative said, very safe [person's name] care is fantastic. I couldn't be happier with it."

Another said, "Concerns none whatsoever"

[Wonder if CQC feed their findings back to them]

63/

Staff had received training and were able to tell us the correct action to take if they suspected people were at risk of abuse. The provider had clear policies and procedures in relation to safeguarding adults.

However, these policies were not always followed.

[Of course]

64/

For example, we spoke with both assistant managers about a recent safeguarding referral.

Information relating to the incident could not be found nor was it used to inform the person's care plan/risk assessment.

[This place is dangerous]

65/

Systems were either not in place or robust enough to demonstrate accidents and incidents were effectively monitored, reviewed or used as a learning opportunity.

66/

The provider had failed to ensure all risks to the safety of people receiving care and treatment were appropriately assessed, mitigated or effectively managed.

This placed people and staff at increased risk of avoidable harm.

67/

This was a breach of Regulation 12 of the Health and Social Care Act 2008 (regulated activities) Regulations 2014.

[I guess no surprise given they've still not acted on recommendations made 13yrs previously; they have probably learnt there's no consequence of not doing so]

68/

People were not always protected by safe recruitment practices.

We looked at the recruitment information for two staff members. Whilst some recruitment checks had been carried out, others had not.

69/

One staff file did not contain full employment history; provider had failed apply for a Disclosure and Barring Service check.

Provider was unable demonstrate they had followed a thorough recruitment process in accordance with Schedule 3 of Health and Social Care Act 2008

70/

We discussed what we found with provider who assured us they had checked the staff members DBS status and agreed to send us confirmation.

Following inspection, we received the DBS check confirmation however, this was dated after the inspection.

[Duty of candour anyone]

71/

The failure to establish and operate safe and effective recruitment procedures is a breach of Regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

[And the deliberate attempt to mislead? What regulation does that break?]

72/

Medicines were not always stored or managed safely.

Medicines due be returned to pharmacy for safe disposal were not stored securely.

These medicines were stored in a place which could be accessed by all staff, visitors and people living at the service.

73/

[Medicines management raised Feb09... still not sorted 13 yrs later]

In most cases staff assessed level of support each person needed with their medicines, and recorded consent to administer.

However, this not been completed for one person living in service for over 6mths

74/

When people were prescribed medicines 'when required' there were protocols to guide staff when they might be needed.

However, these lacked person-centred details, and did not always match with the printed instructions on the label or medicines administration chart.

75/

One person who was prescribed a sedative medicine had a maximum dose written on the protocol which was higher than that prescribed.

[Of course, just drug them up, overdose on sedative, doesn't matter does it. How can this be?]

76/

Staff received training in safe medicine administration.

However, there was no formal system of checking staff competencies and no records to show these checks were regularly carried out.

[Pointless tickbox training]

77/

Staff were not aware of 'STOMP' initiative (to stop over medication of people with a learning disability, autism or both).

The failure to manage people's medicines safely is a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regs 2014

78/

People were not protected from the risk and spread of infection.

We were not assured the provider was doing everything possible to prevent people, visitors and staff from catching and spreading infections.

79/

Whilst the provider had in place procedures for visitors and staff entering the service, these were not always being followed.

On the first day of the inspection an assistant manager allowed the inspector to enter the service without checking their temperature, screen...

80/

...them for possible symptoms or potential exposure to COVID 19 or ask them to produce evidence of a recent LFD (lateral flow device) test.

We were not assured that staff were using PPE effectively and safely.

81/

On the first day of our inspection we observed a senior member of staff was not wearing a suitable face mask.

They told us they had not worn a face mask since October 2021 due to medical reasons.

82/

We discussed what we found with provider who told us they had taken advice and been advised by a healthcare professional that the staff member should wear a face mask.

No action had been taken following this advice to reduce / mitigate the risk or transmission of COVID 19

83/

[What is the point of taking advice, and not acting on it?

What is the point of asking for action plans, writing actions plans and not acting on them?

What is the point of training or policies if they aren't implemented?]

84/

We were assured that the provider's infection prevention and control policy was up to date, however this was not always being followed.

[Pointless performative policies - just tick a box and carry on regardless]

85/

The failure to effectively manage risks relating to infection control and the transmission of COVID-19 is a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

86/

[Effective - requires improvement]

Last inspection we rated this requires improvement.

This inspection the rating has remained requires improvement.

The effectiveness of people's care, treatment and support did not always achieve good outcomes or was inconsistent.

87/

People's needs were not always assessed before they started using service.

Person moved in in Sept 2021, at inspection person did not have a pre-admission assessment, a care plan or any assessment of risks associated with their needs or provision of their care and support.

88/

Another person had moved into the service in August 2021, staff told us they did not have access to a care/support plan or provided with any guidance on how they should meet this person's care and support needs until April 2022, when a support plan was created.

89/

One person's pre-admission assessment identified they had epilepsy and potentially could place themselves, staff and others at risk by their actions during times of emotional distress.

This information did not form part of this person's care and support plan.

90/

Staff told us they had not been provided with any guidance to enable them to support this person effectively.

Providers failure to ensure that people's needs were assessed is a breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regs 2014

91/

At the two previous inspections in February and October 2019 we found people were not always supported to have maximum control over their lives and senior staff were not consistently applying the principals of The Mental Capacity Act 2005 (MCA).

92/

This was a breach of regulation 11 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

At this inspection we found not enough improvement had been made and the provider was still in breach of regulation 11

93/

People were not supported to make decisions about their care as staff did not fully understand their roles and responsibilities under the Mental Capacity Act 2005 (MCA) including Deprivation of Liberty Standards.

94/

Where restrictions had been placed on person to keep them safe through use of a lap belt, this was not recognised by staff as restrictive practice and person's capacity to consent to these arrangements had not been considered nor had staff followed a best interests process

95/

We reviewed a number of people's capacity assessments and found they had been poorly completed.

For example, none of the MCA assessments contained any information about how people were being supported to understand, retain, weigh up or communicate their decision.

96/

Mental capacity assessments did not contain any details of the person's views/preferences or wishes, therefore there was no evidence of the involvement of the person in the process.

97/

Staff's lack of knowledge and understanding of MCA, had led to them undertaking Mental capacity assessments on service users whether they had capacity or not.

This blanket approach combined with a failure to be person and decision-specific created a disempowering culture.

98/

We discussed what we found with one of the services assistant managers who said,

"I thought it was best just to carry out MCA assessments on everyone."

[Everyone. But not for the decisions that would actually require an assessment. Known failings around MCA for years]

99/

[June 2014, 8yrs ago, inspector noted:

We were unable to find documentary evidence of consideration of capacity under the Mental Capacity Act 2005, or of Best Interest Decision meetings regarding important decisions such as medication]

100/

The providers continued failure to properly assess and record people's capacity and/or best interest decisions risked compromising people's rights.

This was a continued breach of regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

101/

At the last inspection we found the providers failure to ensure staff had been provided with appropriate training and supervision potentially placed people and staff at risk.

This was a breach of regulation 18 of the Health and Social Care Act 2008

102/

At this inspection we found not enough improvement had been made and the provider was still in breach of regulation 18.

The provider told us they had invested in a new training system and staff told us they had access to training and supervisions.

103/

However, the findings of our inspection demonstrated that staff support, and training was not effective.

There was limited evidence available to demonstrate the providers oversight through supervision or appraisal of staff's work performance.

104/

During our discussions with managers and staff we found there were clear gaps in their knowledge for example in relation to the Mental Capacity Act 2005, risk management, infection prevention and control, fire and positive behavioural support.

105/

None of the staff we spoke with including the managers were aware of or able to describe the underpinning principles of Right support, right care, right culture guidance (choice, control, independence, inclusion) and how this might increase people's quality of life.

106/

[That's alright, they'll no doubt buy an online training package.

Staff will watch it, learn by rote what they're meant to say.

Not apply it, embody it, not change anything.

Training is not the answer when a culture is this crook.

Over a decade of failing the basics]

107/

Providers supervision policy stated, staff at Burlington House who supported ppl with a learning disability or autism, will be offered clinical supervision in addition to scheduled supervision.

This was not in place and assistant managers was unaware of this.

108/

[Policies full of promises and hot air.

Never never distant land where lives are lived, people are actually safe, and staff are supported to provide care and support that enables people to live their lives]

109/

[Before anyone jumps on to tell me how little providers are paid... in 2009 fees were £350 - £628.25 pounds per week based on social services assessment of needs of each resident.

Even if 12ppl were £350per wk, and one £628.25 that's still £5k per week, £250k per year]

110/

[Even if fees hadn't changed since 2009, that's still £3.25mill turnover since CQC first found they needed to make changes.

Torbados is not an expensive place to live.

A search of sold House Prices shows the house next door sold for £45k in Feb 1999].

111/

[They're clearly not investing a lot in upkeep of the building, or indeed in keeping up to date with policy, regulatory, societal change

It makes me so angry.

And I'm baffled/demoralised by families thinking its ok, such low ambition.

Back to the latest report]

112/

The failure to provide adequate support and training to staff in order to meet people's needs was a breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

113/

Burlington House is set over two floors, within two separate but adjoining buildings.

Following the inspection in January 2019, we issued a 'notice of decision' to impose a condition on the providers registration.

114/

This required the provider to establish a comprehensive refurbishment plan and provide the Care Quality Commission with monthly updates.

The provider had failed to provide this information.

At this inspection we found environmental improvements were still needed

115/

For example, carpets remained worn, frayed and heavily stained in places and in one area taped together

Some walls needed painting and some equipment was not clean.

[Carpets taped together.... 21st century care and support, Torquay style]

116/

We noted the lounge within the 'annex' where three people lived continued to be used as a storage area for people's personal belongings.

Assistant managers told us they did not have a refurbishment plan in place.

117/

This was a breach of Regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

[Please just shut it down.

These people deserve more]

118/

[Caring - requires improvement]

At our last inspection we rated this key question good.

At this inspection the rating has changed to requires improvement.

This meant people did not always feel well-supported, cared for or treated with dignity and respect.

119/

People living at the service were encouraged to make some decisions about day to day matters such as food and clothing.

Staff told us people were supported to express their views and were involved as far as possible in making decisions about the care and support provided.

120/

However, more work was needed to ensure people were truly involved and seen as partners in their care.

Staff were not able to tell us how they were engaging people in understanding their rights, supporting them to have increased opportunities or make informed decisions.

121/

Altho we observed many positive interactions between people and staff during the inspection.

Language sometimes used by staff to describe interactions with people did not always demonstrate a person-centred approach or show they were valued as equal partners in their care

122/

During the inspection we heard one person telling one of assistant managers that they did not want to go on holiday to 'Butlins,' they wanted to go to 'Eastbourne' instead.

The assistant manager replied "It doesn't matter anyway because we don't have the staff to take you"

123/

[An assistant manager.

Being cruel, to a resident.

In front of a @CareQualityComm inspector.

Seriously, this place is toxic, even if relatives can't see it and people don't expect more]

124/

Records showed another assistant manager had written an incident report form because the person had refused to follow their directions.

[Oh wow. Total control. Closed cultures. An absolute petri dish for abuse.

That's the care and support at Burlington Care and Support]

125/

Most people living at the service had a support plan which contained basic information about their support needs, likes and interests.

However, these were often outdated and not being reviewed in line with people's changing needs.

126/

The failure to ensure that people were supported and empowered to have choice and/or control over the way they were cared for is a continued breach of regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

[Another. Continued Breach]

127/

People's basic human right to privacy and confidentiality was not always considered or respected by managers and staff.

For example, following the previous inspection in October 2019 a decision had been made to move the main office into the quiet lounge downstairs.

128/

This meant that one person had to go through the office to access their bedroom.

Throughout the inspection staff shared private and confidential information about people and staff with inspectors, seemingly unaware that the person and staff at times were in this bedroom.

129/

Both assistant managers told us they had not fully considered the implications of having a person's bedroom within the office and how this might impact on the day to day running of the service.

[Only concerned with the impact on them, not on the person who is living there]

130/

People's personal records were not kept secure and confidential as the door to the office could not be locked and was accessible to all the people living at the service staff and visitors.

[Imagine. That being your home. Or that being the disregard for your privacy]

131/

The failure to ensure people were treated with privacy and dignity is a breach of regulation 10 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

132/

People's support plans now contained more information about what each person could do for themselves, although they continued to be less clear about how people could/should be supported to develop their life skills and increase their independence.

[Non-lives]

133/

[Responsive - requires improvement.

You think? This place has been failing for 13 years, in plain sight.

How it can't be rated inadequate on this point is beyond any logical sense. It had a condition imposed on its registration by @CareQualityComm that it ignored FFS]

134/

At our last inspection we rated this key question requires improvement.

At this inspection the rating for this key question has remained requires improvement.

This meant people's needs were not always met.

135/

At the last inspection, we found people were at risk of not receiving care and support that was personalised and reflective of their needs because support plans lacked sufficient detail.

This was a breach of regulation 9 of the Health and Social Care Act

136/

At this inspection not enough improvement had been made. Provider was still in breach of Reg 9.

People's care records contained more info about goals and future aspirations. More work was needed to ensure ppl's opportunities were not limited by their own life experience.

137/

People's records contained details of short-term needs/wants and everyday activities that most people take for granted.

Like buying things they wanted or needed, going out for a meal, watching TV or taking part in arts and crafts.

138/

Records contained limited information about any action that had or could be taken to encourage and support people to broaden their horizons, develop life skills or try new experiences.

139/

People were not being supported or empowered to have choice or control over the way they were cared for and as such were not truly part of the care planning process.

140/

Care and support records were not being regularly reviewed or updated.

Where reviews had taken place there was no evidence to demonstrate that people were involved or show their views/wishes had been sought and used to inform their care and support.

141/

People's communication needs were not always being met.

The service did not identify, record and meet the communication needs of all the people living at Burlington House.

[They didn't comply with @CareQualityComm demands for a decade, they just don't care]

142/

Support plans had not been developed in an accessible format, such as easy read or pictorial.

One person was keen to show us their support plan but said they did not know what it contained as they could not read it.

[I just can't. My brain is screaming]

143/

The providers failure to ensure each person had a care and support plan designed to achieve their needs, wishes and preferences and ensure staff provided person-centred care and support was a continued breach of regulation 9 (Person centred care)

144/

[Can you imagine, being that keen to show your care plan off to the inspector, probably the highlight of your week, but not being able to read it.

Or having to goto your bedroom through the feckin office.

This place is a hell hole. It needs shut down]

145/

Assistant manager described how they were working with people and their care managers (Local authority) to ensure people were not socially isolated and had increased opportunities within the community eg attending day centres or identifying opportunities for work experience

146/

Opportunities remained limited for most people living at the service. Provider told us increased opportunities very much depended on staffing and funding allocated by LA and described how they were working with one care manager to prevent a reduction in 1-1 support/ funding

147/

[Oh I bet they were. Even tho there's no evidence anyone gets support to do anything.

But the business couldn't miss out on the dosh.

How is this so obvious, yet so ignored?]

148/

[Well-led is inadequate]

At our last inspection we rated this key question requires improvement.

At this inspection the rating has changed to inadequate.

This meant there were widespread and significant shortfalls in service leadership.

149/

Leaders and the culture they created did not assure the delivery of high-quality care.

At the previous inspection, October 2019, whilst we found some improvements had been made the service needed time to fully embed those changes.

[13 years aint long enough]

150/

We recommended that the provider continued to review the systems in place to monitor the service to ensure compliance with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

At this inspection we found improvements had not been sustained.

151/

Providers failure act upon feedback from previous inspections and enforcement action taken by @CareQualityComm meant service was not compliant with regulations; service users continued be exposed to risk of harm and provider was in breach of condition of their registration

152/

[Just shut it down.

We have excellent @SharedLivesSW provision in this area.

Support people to move, so they can have a life, before they lose their life]

153/

The providers oversight and governance of the service was inadequate in identifying the serious failings in relation to the safety, quality and standard of the service as detailed in the safe, effective, caring and responsive sections of this report.

154/

For example, the providers told the inspector that they were shocked to find out that some people did not have a pre-admission assessment or care plan in place or that care reviews had stopped taking place.

[Shocked. They were shocked. It's their service]

155/

Leaders did not have the skills, knowledge and experience to perform their roles. The culture of the service did not reflect best practice guidance for supporting people with a learning disability and/or autistic people.

156/

Managers and staff, had no understanding of Right support, right care, right culture guidance published by @CareQualityComm

[It's a totally contemptuous disregard for the basics]

157/

...or how the underpinning principles could be used to develop the service in a way which supported and enabled people to live an ordinary life, enhanced their expectations, increase their opportunities and value their contributions.

[They just don't care]

158/

The provider and managers failure to follow and embed the services own policies and procedures which were designed to support staff, assess and monitor quality within service delivery.

[They've been failing to follow and embed them for 13 years. How is this allowed?]

159/

For example, in relation to care planning, risk management, mental capacity, positive behavioural support, epilepsy, supervision, and infection prevention and control.

160/

Systems were not in place to demonstrate accidents and incidents were effectively monitored, reviewed or used as a learning opportunity.

When things had gone wrong, the potential for reoccurrence was high because insufficient action had been taken

161/

Regular medicines audits did not identify the concerns we found at this inspection.

[Burlington Care and Support failing medications management since 2009]

162/

Poor judgements/decision making potentially placed people at risk of harm.

Providers failure act on advice provided by external health and social care professional and to adhere to their own PPE Policy and Procedure, placed ppl, staff and visitors at increased risk of harm

163/

Records and checks undertaken by managers and staff were not always accurate and as such could not be relied upon.

An assistant manager said they had taken home audits relating to PPE and Infection control from June 2021 to complete retrospectively.

164/

[Imagine admitting to a @CareQualityComm inspector that you're fiddling the paperwork. I mean the contempt and/or ignorance is palpable]

This meant they were not an accurate or contemporaneous reflection of their observations.

165/

Governance systems and processes had not identified that records were not always accurate or fully completed.

The provider was unaware care reviews had stopped taking place, that environmental risks had been identified but action had not been taken or that...

166/

...information relating to a safeguarding incident could not be found

[What the hell is going on. How can all this be allowed to happen in plain sight? @Torbay_Council can you send someone from your safeguarding team around to this place, asap]

167/

People were not involved in a meaningful way in the development of their care and support and information was not provided in a way which met people's individual communication needs.

168/

Managers who were in day to day control of the service had limited understanding of how to support people in accordance with the Health and Social Care Act 2008 and seemed to be unaware of the culture they were creating within the service.

169/

For example, institutionalised practices, in the form of weekly hand washing for all people living at the service had been introduced and described as evidence of good practice.

170/

[Ok, I have tried so hard to be professional. To not swear, but I'm seriously struggling here. The dog two doors down has been howling for the last hour since his owner went out and it's a perfect metaphor for how I feel. WTAF? Weekly hand washing?]

171/

The provider had not ensured the staff understood the principles of the MCA.

This lack of knowledge and understanding risked compromising people's rights.

[Only risked?]

A poor staff culture created a lack of professional challenge that impacted on people's safety.

172/

Whilst it was clear that staff cared about people the culture of the home was not one where people were encouraged and supported to be the best version of themselves.

[If this was a family it wld be called neglect, authorities would intervene. What are they waiting for?]

173/

The provider had not ensured the quality and safety of the service had been adequately assessed, monitored or improved to ensure it met with regulatory requirements and best practice guidance.

174/

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

[Another. Continued. Breach]

175/

Relatives we spoke with continued to have confidence in service and told us the service was well managed.

Comments included "There's a very good manager who instils a certain ethos" and "I think it's well managed, I've never had any worries, but I would ring them if I did"

176/

[Instils a certain ethos alright.

Relatives clearly lack ambition for their loved ones to have a life then. Which is where #socialwork is meant to step in.

This is horrific. I feel so deeply conflicted about the reports of relatives thinking all is ok]

177/

The registered provider and assistant managers understood their responsibilities in relation to duty of candour.

[OK so they understand them; do they uphold them? What do you reckon?]

178/

However, the provider had not notified the Care Quality Commission of an incident which had been reported to, or investigated by, the police in line with their legal responsibilities.

[The police]

179/

This was a breach of regulation 18 of the Care Quality Commission (Registration) Regulations 2009 (part 4).

The registered provider had failed to notify the @CareQualityComm of a death of a person who used the service in line with their legal responsibilities.

180/

[What's not clear is whether these are related failings]

This was a breach of regulation 16 of the @CareQualityComm (Registration) Regulations 2009 (part 4)

[CQC have asked them, again, to send a report, of what they'll do. Yes honestly 🤬

Please just shut it down]

/END