Time for some inadequate care, I can't switch off when I know they're there for sharing, so might as well get on with it.
First up Centurion Health Care Ltd Penley Grange api.cqc.org.uk/public/v1/repo…
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First up Centurion Health Care Ltd Penley Grange api.cqc.org.uk/public/v1/repo…
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Just a reminder from here on tweets will be quotes from the report, I may remove the odd word or two if it doesn't affect meaning but helps brevity.
My own commentary, thoughts, sarcasm and cynicism will be added in [square brackets] from here on in. Thank you for reading
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My own commentary, thoughts, sarcasm and cynicism will be added in [square brackets] from here on in. Thank you for reading
2/
Penley Grange is a residential care home. The service was supporting five people at the time of our inspection and can support up to six people. The service is adjoined to a separately registered care home operated by the same care provider.
3/
3/
[Before we get to Penley Grange, I had a quick look at the other home on the same site, Penley View api.cqc.org.uk/public/v1/repo…
Sorry to say its pretty grim. They were inspected earlier this year as a result of safeguarding concerns. The report says:]
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Sorry to say its pretty grim. They were inspected earlier this year as a result of safeguarding concerns. The report says:]
4/
The inspection was prompted in part due to safeguarding concerns received about nutrition, delayed medical intervention and staff interactions towards a person.
[Grim, grim, grim]
5/
[Grim, grim, grim]
5/
We also received concerns about poor management oversight, staffing levels and staff training. A decision was made for us to inspect and examine those risks.
The inspection was also prompted in part by notification of a specific incident.
6/
The inspection was also prompted in part by notification of a specific incident.
6/
Following which a person using the service sustained a serious injury.
This incident is subject to a criminal investigation.
As a result, this inspection did not examine the circumstances of the incident.
[No words]
7/
This incident is subject to a criminal investigation.
As a result, this inspection did not examine the circumstances of the incident.
[No words]
7/
Information CQC received about the incident indicated concerns about management of accidents and incidents and seeking timely medical interventions. This inspection examined those risks.
[Penley View is inadequate, in special measures; the report makes for brutal reading]
8/
[Penley View is inadequate, in special measures; the report makes for brutal reading]
8/
[So back to this report, Penley Grange]
People did not always live safely.
This was because the service did not assess, monitor or manage people's safety well, including risks of abuse and risks posed by the behaviours of people using the service.
9/
People did not always live safely.
This was because the service did not assess, monitor or manage people's safety well, including risks of abuse and risks posed by the behaviours of people using the service.
9/
The service had failed to consistently make contact with other relevant agencies, when incidents or concerns occurred, to protect people from the risk of abuse.
Where concerns had been identified and reported, this had not always been achieved in a timely manner.
10/
Where concerns had been identified and reported, this had not always been achieved in a timely manner.
10/
Staff members did not always treat people with kindness, dignity and respect, including respect for people's privacy.
People were not consistently supported to express their wishes and engage with staff using their preferred methods of communication.
11/
People were not consistently supported to express their wishes and engage with staff using their preferred methods of communication.
11/
Staff recruitment, induction and ongoing training processes did not promote safety, including those for agency staff.
The skills and deployment of staff did not match the needs of people using the service.
12/
The skills and deployment of staff did not match the needs of people using the service.
12/
People did not have opportunities to learn new skills or try new experiences due to the limited variety of onsite and off-site activities people were supported to participate in.
13/
13/
Care plans were not holistic, strengths based and did not capture people's preferences and aspirations.
We have made a recommendation in relation to end of life care planning.
14/
We have made a recommendation in relation to end of life care planning.
14/
People's relatives told us they had generally been involved in key decision making, however records showed the service did not consistently consult people's relatives when accidents or incidents occurred.
15/
15/
Relatives felt communication could be improved, although indicated there had been some recent signs of improved communication since a care consultancy was engaged to help manage the service, including contact with relatives about some incidents which had occurred.
16/
16/
Governance processes had not been operated effectively to keep people safe, provide good quality care and protect people's rights.
A care consultancy had recently been commissioned by the provider to develop an action plan and support the service to make improvements.
17/
A care consultancy had recently been commissioned by the provider to develop an action plan and support the service to make improvements.
17/
At the time of our inspection we observed environmental works taking place but a number of other planned changes had not yet been implemented, or were not yet embedded, meaning we could not observe significant improvements to people's experience of using the service.
18/
18/
We also made a recommendation in relation to provider's responsibility to meet the duty of candour.
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
19/
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
19/
The service had purchased a new suite of policies which were due to be implemented to promote best practice.
The service was not able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture.
20/
The service was not able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture.
20/
People were not consistently supported by staff to pursue their interests, or to identify their aspirations and goals.
Staff did not always communicate with people in ways that met their needs.
21/
Staff did not always communicate with people in ways that met their needs.
21/
People were not supported in a safe, well-maintained environment that met their sensory needs.
People did not always receive kind and compassionate care.
Staff did not consistently take action to protect and respect people's privacy and dignity.
22/
People did not always receive kind and compassionate care.
Staff did not consistently take action to protect and respect people's privacy and dignity.
22/
Staff did not consistently understand and act to protect people from poor care and abuse.
People were not supported to lead inclusive and empowered lives.
23/
People were not supported to lead inclusive and empowered lives.
23/
The service had failed to consistently evaluate the quality of support provided to people or ensure risks of a closed culture were minimised so that people received support based on transparency, respect and inclusivity.
Last rating was Good (published 8 November 2017).
24/
Last rating was Good (published 8 November 2017).
24/
The inspection was prompted in part due to concerns about poor management oversight following concerns raised about the quality and safety of people's care at the adjoined care home.
25/
25/
We had also received concerns in relation to the service, including concerns about quality of people's care, staff culture and management of risks.
We found evidence that provider needs to make improvements.
Overall rating for service has changed from good to inadequate
26/
We found evidence that provider needs to make improvements.
Overall rating for service has changed from good to inadequate
26/
We have identified breaches in relation to safe care, safeguarding from abuse, person centred care, dignity and respect, consent to care, staffing levels and suitability, nutrition and hydration, suitability of the environment, management of complaints...
27/
27/
...staff training, governance and leadership and reporting of incidents.
The overall rating for this service is 'Inadequate' and the service is therefore in 'special measures'.
28/
The overall rating for this service is 'Inadequate' and the service is therefore in 'special measures'.
28/
The service's registered manager was no longer in post at the time of our inspection, and was not involved in the inspection process.
This inspection was unannounced.
29/
This inspection was unannounced.
29/
[Safe - inadequate]
At the last inspection this key question was rated as Good. At this inspection this key question has now deteriorated to Inadequate.
This meant people were not safe and were at risk of avoidable harm.
30/
At the last inspection this key question was rated as Good. At this inspection this key question has now deteriorated to Inadequate.
This meant people were not safe and were at risk of avoidable harm.
30/
We reviewed safeguarding records from 2018 until the recent departure of registered manager.
There was no system in use to log, monitor or investigate safeguarding concerns.
Registered manager had failed to report concerns to the local safeguarding authority as required.
31/
There was no system in use to log, monitor or investigate safeguarding concerns.
Registered manager had failed to report concerns to the local safeguarding authority as required.
31/
[The @CareQualityComm currently shows Mrs Andrea Brown as registered manager of Penley Grange and Penley View; and a number of website online have her listed as the registered manager 2yrs ago.
Wonder if any/what action will be taken for such failings]
32/
Wonder if any/what action will be taken for such failings]
32/
On 19 April 2022 we found 4 safeguarding referrals had been submitted since start of April 2022.
The safeguarding log and documented referrals did not include incidents logged on 1 April and 7 April 2022 where a person had slapped and hit other people using the service.
33/
The safeguarding log and documented referrals did not include incidents logged on 1 April and 7 April 2022 where a person had slapped and hit other people using the service.
33/
The April 2022 safeguarding log did include five concerns which were marked as 'open'.
This indicated some improvement in reporting and recording, however this was inconsistent
34/
This indicated some improvement in reporting and recording, however this was inconsistent
34/
incident report forms continued to be incomplete and did not contain enough information about how the service was managing safety effectively.
Incidents on 23 April 2022 and 24 April 2022 were not reported to the local authority until 11 May 2022.
35/
Incidents on 23 April 2022 and 24 April 2022 were not reported to the local authority until 11 May 2022.
35/
This meant we could not be assured the service was identifying, responding to and reporting safeguarding concerns in a timely manner.
The nominated individual advised on some occasions staff failed to complete the correct documentation which had contributed to delays.
36/
The nominated individual advised on some occasions staff failed to complete the correct documentation which had contributed to delays.
36/
Some staff used incident/accident forms to log potential safeguarding concerns, frequently completing page one of three only.
[Partial performative scrutiny]
37/
[Partial performative scrutiny]
37/
The care consultant was not aware of pages two or three of the forms, and told us they did not sign the forms to confirm they had been reviewed and did not make comments on the forms about actions taken to demonstrate how people were safeguarded.
38/
38/
We identified a body chart dated 4 April 2022 showing scratches to one person's back.
The document provided no explanation about how the scratches occurred and the nominated individual confirmed no investigation was completed.
39/
The document provided no explanation about how the scratches occurred and the nominated individual confirmed no investigation was completed.
39/
Another body chart, dated 3 April 2022 showed unexplained bruising around a person's eye.
The bruising had been reported to the local authority safeguarding team.
40/
The bruising had been reported to the local authority safeguarding team.
40/
There was no accessible record of an internal investigation to explore the potential cause of the bruising and therefore we could not be assured the service had taken all reasonable steps to consider any potential measures which could be implemented to safeguard the person.
41/
41/
People were not protected from risks of abuse associated with people's behaviours.
We observed one person push another person on their shoulder.
The push did not appear to be forceful but the person who was pushed looked around and had a worried expression on their face.
42/
We observed one person push another person on their shoulder.
The push did not appear to be forceful but the person who was pushed looked around and had a worried expression on their face.
42/
[Looking the other way to abuse in homes, from staff or other residents, is pervasive and devastating.
Cpl weeks ago I reported Robert Chaplin's inquest, he died following a fight with another resident where he was living. Apparently no-one cld have anticipated it, yet...]
43/
Cpl weeks ago I reported Robert Chaplin's inquest, he died following a fight with another resident where he was living. Apparently no-one cld have anticipated it, yet...]
43/
The agency staff member present did not acknowledge this with either person.
The staff member followed the person around, rather than engaging the person in meaningful activities or anticipating the potential risk of the person hitting or grabbing others.
[Non-care]
44/
The staff member followed the person around, rather than engaging the person in meaningful activities or anticipating the potential risk of the person hitting or grabbing others.
[Non-care]
44/
During inspection visits the same person consistently pushed, grabbed and pulled inspectors forcefully.
We also witnessed a person being hit, a contractor was pushed and a staff member was forcefully pushed against a door.
45/
We also witnessed a person being hit, a contractor was pushed and a staff member was forcefully pushed against a door.
45/
Staff supporting the person did not consistently implement identified preventative strategies or respond effectively to early warning signs to take steps to prevent behaviours from escalating.
46/
46/
We observed occasions where staff were following the person and then once the person had already engaged in distressed behaviours, staff told the person to stop, let go or held the person's hand and tried to lead them away.
47/
47/
One person told us they felt upset when the person shouted.
There was an ongoing risk of distress and injury to the person and others.
[This is so unacceptable, for the person who is distressed, and those living with them. Miserable existences for all]
48/
There was an ongoing risk of distress and injury to the person and others.
[This is so unacceptable, for the person who is distressed, and those living with them. Miserable existences for all]
48/
The nominated individual told us the number of different visitors to the service throughout March 2022 onwards contributed to the person feeling unsettled.
This was not reflected in the person's care plans and risk assessments at the time of our visit.
49/
This was not reflected in the person's care plans and risk assessments at the time of our visit.
49/
Staff and the nominated individual also described other triggers for the person's actions, including boredom.
Staff we spoke with had varying levels of understanding in relation to signs of abuse and how to escalate concerns.
50/
Staff we spoke with had varying levels of understanding in relation to signs of abuse and how to escalate concerns.
50/
Records showed safeguarding training was up-to-date for only 4 of 15 staff, with training for other staff being incomplete or overdue refresher.
Systems and processes were not established and operated effectively to prevent abuse of service users or to investigate concerns.
51/
Systems and processes were not established and operated effectively to prevent abuse of service users or to investigate concerns.
51/
This was a breach of Regulation 13 (Safeguarding service users from abuse and improper treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
52/
52/
An action plan was in place.
This stated the service would review the previous three months incident records to identify safeguarding concerns.
[There's details in the report, I'll not repeat them here - everything in process, always future improvements]
53/
This stated the service would review the previous three months incident records to identify safeguarding concerns.
[There's details in the report, I'll not repeat them here - everything in process, always future improvements]
53/
Risk assessments were either not present, had not been updated in a timely manner, or lacked sufficient detail to help staff understand and respond to risks.
[So what is the point of a risk assessment then? Just window dressing?]
54/
[So what is the point of a risk assessment then? Just window dressing?]
54/
Four people's care records contained an undated risk document entitled "How to support [person] safely", which rated hazards as low, medium or high.
There was no explanation or rationale about how respective ratings were assessed.
55/
There was no explanation or rationale about how respective ratings were assessed.
55/
For example, there was no reference to the likelihood of occurrence or severity of outcome.
There was no evidence the risk assessments had been subject to regular review.
One person's care file contained a positive behaviour support (PBS) plan, dated 11 November 2021.
56/
There was no evidence the risk assessments had been subject to regular review.
One person's care file contained a positive behaviour support (PBS) plan, dated 11 November 2021.
56/
The PBS plan stated staff should move other people away to maintain safety.
There was no information about how to do this or what to do if other people declined to move.
57/
There was no information about how to do this or what to do if other people declined to move.
57/
A staff member told us they would use their body to come in between the person and others, saying to the person, "pushing is no good".
This intervention was not documented in any of the person's care plans or risk assessments.
58/
This intervention was not documented in any of the person's care plans or risk assessments.
58/
There was another 'Behavioural support plan', undated, which stated if the person pulled at staff they were to tell him "Hands down".
This was not included in the PBS plan dated 11 November 2021.
59/
This was not included in the PBS plan dated 11 November 2021.
59/
Both documents were in the person's file and it was unclear which one staff should follow, which meant staff may not know how to support the person appropriately to prevent and reduce the risk of harm.
[Dangerous PBS distraction again]
60/
[Dangerous PBS distraction again]
60/
Another person's risk assessment did not consider their potential risk of falls.
A staff member advised the person used the stairs slowly.
They explained they monitored to ensure they were using the banister and reminded them to be careful when placing their feet.
61/
A staff member advised the person used the stairs slowly.
They explained they monitored to ensure they were using the banister and reminded them to be careful when placing their feet.
61/
Incident records showed the person had recently fallen on the stairs.
There was no evidence a risk assessment had been carried out in response to the fall.
62/
There was no evidence a risk assessment had been carried out in response to the fall.
62/
Staff practice placed people at increased risk of harm.
We observed two staff members assisting someone to stand from a trampoline, placing their hands under the person's upper arms. This was not done forcefully.
63/
We observed two staff members assisting someone to stand from a trampoline, placing their hands under the person's upper arms. This was not done forcefully.
63/
Another staff member told us they held the person's hands to help pull them up. These approaches could have placed the person or staff at risk of injury.
Care records contained no risk assessment or guidance about how to assist the person to stand.
64/
Care records contained no risk assessment or guidance about how to assist the person to stand.
64/
Records showed moving and handling training was incomplete or overdue refresher for all but one member of staff.
[All but one. The basics]
Another person's risks in relation to epilepsy were not well managed.
[Apathetic epilepsy care, again]
65/
[All but one. The basics]
Another person's risks in relation to epilepsy were not well managed.
[Apathetic epilepsy care, again]
65/
The staff notice board included an undated seizure protocol which referred to rescue medicine.
The person's care folder included an epilepsy risk assessment but did not refer to rescue medicine.
66/
The person's care folder included an epilepsy risk assessment but did not refer to rescue medicine.
66/
There was no supply of rescue medicine on-site and a prescription was requested in response to our feedback.
[Hoooooowwwwwwww]
We asked a staff member how they would respond to a seizure.
67/
[Hoooooowwwwwwww]
We asked a staff member how they would respond to a seizure.
67/
They could not locate written guidance, and told us they would shout at the person to wake up, and if they didn't respond would call an ambulance.
This was not in line with the protocol or risk assessment.
[Shouting. The unknown miracle non-response to epilepsy]
68/
This was not in line with the protocol or risk assessment.
[Shouting. The unknown miracle non-response to epilepsy]
68/
Another person experienced a visual impairment.
A risk assessment advised they were at risk of tripping or falling over unseen objects and described support required in the community.
There were no risk reduction measures in relation to the service.
69/
A risk assessment advised they were at risk of tripping or falling over unseen objects and described support required in the community.
There were no risk reduction measures in relation to the service.
69/
For example, the assessment did not consider use of stairs, the uneven garden or risks the person was unable to see another person approaching who was known to physically assault them.
[This is horrific. Imagine living in that environment]
70/
[This is horrific. Imagine living in that environment]
70/
Another person's care plan confirmed they had a diagnosis of epilepsy.
We asked four members of staff and one agency staff, who had a history of epilepsy.
Staff did not identify the person.
[Could not even identify the person. No idea]
71/
We asked four members of staff and one agency staff, who had a history of epilepsy.
Staff did not identify the person.
[Could not even identify the person. No idea]
71/
Person's care plan contained general info guide about epilepsy, describing different types of seizures, treatments and triggers.
Info was not personalised, meaning there was no information about person's past history of epilepsy, such as when their last seizure occurred.
72/
Info was not personalised, meaning there was no information about person's past history of epilepsy, such as when their last seizure occurred.
72/
Chemicals or substances hazardous to health (COSHH), were not safely stored.
We found chemicals in a kitchen cupboard which had no lock and were advised people had supervised access to the kitchen which was accessed via a keypad.
73/
We found chemicals in a kitchen cupboard which had no lock and were advised people had supervised access to the kitchen which was accessed via a keypad.
73/
We twice found laundry detergent in an unlabelled jug on the floor of the laundry room.
The laundry room was secured with a single bolt at the start of our inspection and on some occasions was found unlocked.
74/
The laundry room was secured with a single bolt at the start of our inspection and on some occasions was found unlocked.
74/
On a subsequent visit to the service the laundry room bolt had been replaced with a keypad lock.
[Inspector induced action]
We found tubs of paint left outside in the garden.
[Why?]
On another visit we found an unlocked cupboard containing hand sanitiser.
75/
[Inspector induced action]
We found tubs of paint left outside in the garden.
[Why?]
On another visit we found an unlocked cupboard containing hand sanitiser.
75/
There was no legionella risk assessment on file.
Water temperature monitoring, and flushing of infrequently used water outlets, was not correctly implemented to monitor and prevent the risk of legionella.
76/
Water temperature monitoring, and flushing of infrequently used water outlets, was not correctly implemented to monitor and prevent the risk of legionella.
76/
We also checked water temperature charts for baths and showers dated April 2022 for the prevention of scalding.
The records contained several gaps without explanation, meaning we could not be assured staff consistently checked water temperatures in line with procedures.
77/
The records contained several gaps without explanation, meaning we could not be assured staff consistently checked water temperatures in line with procedures.
77/
The service's previous fire risk assessment report, dated June 2019, identified several actions with no evidence of these being achieved, such as the training of fire wardens.
78/
78/
The service's recent fire risk assessment report, dated March 2022, also made a number of recommendations, including the need for evacuation drills during sleeping hours which had not taken place at the time of our inspection.
79/
79/
We reported our concerns to the fire service who visited the service.
Their report made a number of recommendations, and after our inspection the service provided evidence to confirm some processes were in place, such as the maintenance of fire alarms.
[Some]
80/
Their report made a number of recommendations, and after our inspection the service provided evidence to confirm some processes were in place, such as the maintenance of fire alarms.
[Some]
80/
Records showed last fire drill was 29 June 2021.
This meant new staff had not participated in a fire drill.
Every 'fire alarm weekly test' between 15 Nov 2021 and 4 April 2022 documented the magnetic door release on the dining room door was not working.
[Wilful neglect]
81/
This meant new staff had not participated in a fire drill.
Every 'fire alarm weekly test' between 15 Nov 2021 and 4 April 2022 documented the magnetic door release on the dining room door was not working.
[Wilful neglect]
81/
The home's maintenance book included an entry dated 20 January 2022 that the fire doors needed repair in the dining room, two bedrooms, TV room and sensory room.
There was no action recorded.
[Nah, fire doors aren't important. Performative scrutiny and zero action]
82/
There was no action recorded.
[Nah, fire doors aren't important. Performative scrutiny and zero action]
82/
Systems had not been established or operated effectively to assess, monitor and mitigate risks to the health, safety and welfare of people using the service.
This placed people at increased risk of harm.
83/
This placed people at increased risk of harm.
83/
This was a breach of Regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
An action plan was in place.
[Course it was. Always non-action plans in place]
84/
An action plan was in place.
[Course it was. Always non-action plans in place]
84/
There were some systems and processes in place to safely store medicines.
However, access to medicines were not always restricted as keys to medicines cabinets were not always secure.
85/
However, access to medicines were not always restricted as keys to medicines cabinets were not always secure.
85/
Staff monitored and recorded the temperature of some medicine's storage areas but not of all.
Therefore, we could not be assured that all medicines were stored according to manufacturer's recommendations and if they remained effective.
86/
Therefore, we could not be assured that all medicines were stored according to manufacturer's recommendations and if they remained effective.
86/
People's medicines were not regularly reviewed to monitor the effects of medicines on their health and wellbeing.
We saw that not all people had records of annual physical health checks or medicines review.
87/
We saw that not all people had records of annual physical health checks or medicines review.
87/
People's medicines care and support was not always consistently recorded in their care plans.
Where there was information about people's medicines in their care plans, they were not always up to date with current prescribed medicines.
[State of this]
88/
Where there was information about people's medicines in their care plans, they were not always up to date with current prescribed medicines.
[State of this]
88/
Most people had one or more medicines prescribed to be administered when required (PRN).
However, there was not always enough information for staff to safely and consistently administer PRN medicines.
89/
However, there was not always enough information for staff to safely and consistently administer PRN medicines.
89/
Some staff were able to give examples of medicines related incidences.
However, it was not clear what learning there was as a result of incidences and how improvements were implemented.
90/
However, it was not clear what learning there was as a result of incidences and how improvements were implemented.
90/
Not all staff had received up to date medicines refresher training or competency assessment in line with providers policy.
Where staff had received training, they told us content of the training was not always relevant to their service type and medicines they administer.
91/
Where staff had received training, they told us content of the training was not always relevant to their service type and medicines they administer.
91/
For example, staff had not been trained on how to administer rectal medicines, although there was a person prescribed emergency rectal medicine.
[They probably couldn't have identified who that was anyhow]
92/
[They probably couldn't have identified who that was anyhow]
92/
Medicine audits were carried out regularly.
However, the audits were not robust and had failed to identify all the concerns relating to medicine management we found during our inspection.
93/
However, the audits were not robust and had failed to identify all the concerns relating to medicine management we found during our inspection.
93/
Staff did not always follow the provider's Medicines Policy when administering medicines.
Two members of staff were required to prepare controlled drug (CD) administration and sign the CD register, however we found that two staff were not always signing the CD register.
94/
Two members of staff were required to prepare controlled drug (CD) administration and sign the CD register, however we found that two staff were not always signing the CD register.
94/
The service had not ensured the proper and safe management of medicines.
This was a breach of Regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
95/
This was a breach of Regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
95/
The service had an action plan in place.
[So mannnny action plans, or rather apathy plans]
We were not assured the provider was effectively managing risks in relation to COVID-19.
We found sign-in procedures were inconsistent.
96/
[So mannnny action plans, or rather apathy plans]
We were not assured the provider was effectively managing risks in relation to COVID-19.
We found sign-in procedures were inconsistent.
96/
On our initial visit, staff did not ask health screening questions or seek evidence of COVID-19 testing, and inspectors were not encouraged to sign in or sanitise their hands.
97/
97/
On another visit we were asked to sign in but needed to prompt staff to view COVID-19 testing evidence.
Staff management of the entrance hall did not promote social distancing between people and visitors.
98/
Staff management of the entrance hall did not promote social distancing between people and visitors.
98/
Staff did not consistently wear face masks when supporting people in close proximity, although the majority of staff did wear face masks appropriately.
99/
99/
Throughout our visit on 14 April 2022 the two staff present were not wearing face masks and both were at times in close proximity to a person using the service.
On another occasion we observed a staff member sitting next to a person wearing a face mask under their nose.
100/
On another occasion we observed a staff member sitting next to a person wearing a face mask under their nose.
100/
We noted two people's care folders included NHS letters to confirm they had previously been identified as clinically extremely vulnerable, however care plans contained no instructions for staff to outline whether additional precautions were still needed to mitigate risk.
101/
101/
At the time of our inspection the government had updated national guidance on 1 April 2022 to advise there is no longer separate guidance for people previously identified as clinically extremely vulnerable, although the government recommends anyone with...
102/
102/
...underlying health conditions takes care to avoid routine coughs, colds and other respiratory viruses.
There was no reference to whether people were at increased risk of COVID-19 or other viruses in their care plans or risk assessments.
103/
There was no reference to whether people were at increased risk of COVID-19 or other viruses in their care plans or risk assessments.
103/
Cleaning schedules were in place and on one occasion we observed staff using a hoover and sanitising surfaces.
However, cleaning schedules, including for the regular sanitisation of door handles, contained several gaps.
104/
However, cleaning schedules, including for the regular sanitisation of door handles, contained several gaps.
104/
The oven appeared greasy and had debris in the bottom of it.
On one occasion we found mops, used for different tasks, stored touching one another.
105/
On one occasion we found mops, used for different tasks, stored touching one another.
105/
On 5 May 2022 we identified items in the fridge without open-date labelling and the chart used to log daily fridge and freezer temperatures had not been completed since 22 April 2022.
106/
106/
We identified concerns regarding the disposal of waste, such as masks, gloves and used lateral flow COVID-19 tests disposed of in bins without bin liners.
We also found staff had stored used lateral flow test kits in a cupboard in the office.
[Why? Why would you?]
107/
We also found staff had stored used lateral flow test kits in a cupboard in the office.
[Why? Why would you?]
107/
We found a glove in the rear garden and a mask on the ground.
COVID-19 testing records were poorly maintained.
A staff member explained testing had only occurred on Mondays, which meant some staff had not undertaken weekly testing.
108/
COVID-19 testing records were poorly maintained.
A staff member explained testing had only occurred on Mondays, which meant some staff had not undertaken weekly testing.
108/
Testing records on-site were incomplete.
We were advised test results had been issued to the registered manager and were not accessible during our inspection.
Records for staff lateral flow testing were inconsistent.
109/
We were advised test results had been issued to the registered manager and were not accessible during our inspection.
Records for staff lateral flow testing were inconsistent.
109/
The care consultancy had recently introduced a log for lateral flow tests, to be monitored as part of daily checks.
However we could not be assured of the effectiveness of these checks.
[What is the point?]
110/
However we could not be assured of the effectiveness of these checks.
[What is the point?]
110/
As on 19 April 2022 we found the care consultant was not aware of who was on duty and the employee sign-in sheet did not match the full list of staff we observed working.
[No words]
111/
[No words]
111/
The COVID-19 policy appeared to be missing key information.
The contents list referred to topics such as 'admissions to the care home', 'visitors' and 'diagnosing COVID-19 in care homes' however there was no content about these areas.
112/
The contents list referred to topics such as 'admissions to the care home', 'visitors' and 'diagnosing COVID-19 in care homes' however there was no content about these areas.
112/
We located a visitors policy dated 30 July 2021, however there was no evidence this had been updated in response to subsequent changes to government guidance.
113/
113/
The provider shared a risk assessment form entitled 'CORONAVIRUS(COVID-19)', dated 10 January 2022, which included measures to reduce risk.
We found these were not always implemented.
114/
We found these were not always implemented.
114/
The nominated individual confirmed the log for staff vaccine uptake was blank.
This meant we could not evidence how the registered manager had verified whether staff had been fully vaccinated against COVID-19.
115/
This meant we could not evidence how the registered manager had verified whether staff had been fully vaccinated against COVID-19.
115/
Was no longer a legal requirement for care staff to be vaccinated as condition of deployment, info regarding vaccine uptake can assist with assessing risk, such as considering risks for service users, particularly those who were identified as clinically extremely vulnerable
116/
116/
The service had not established or implemented robust infection prevention and control procedures to effectively mitigate risk to ppl.
This was a breach of Regulation 12 (Safe care and treatment) of Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
117/
This was a breach of Regulation 12 (Safe care and treatment) of Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
117/
The provider had an action plan in place.
This identified the need for fly screens to be fitted and for monitoring to ensure bin liners were used.
[How on earth can this be considered consultancy advice? How can anyone need to be told to use a bin liner?]
118/
This identified the need for fly screens to be fitted and for monitoring to ensure bin liners were used.
[How on earth can this be considered consultancy advice? How can anyone need to be told to use a bin liner?]
118/
The provider had purchased a suite of policies which were due to be implemented, which included policies for infection control and admissions policy and procedure.
[So much so wrong with this statement; buying a suite of policies to tickbox compliance]
119/
[So much so wrong with this statement; buying a suite of policies to tickbox compliance]
119/
Concerns had been raised about waste bins.
Family member told us
"At entrance the bins were overflowing with bags, in the COVID period, and managers could've done much more to control this. I'm not sure if it's addressed even now because they are still regularly there"
120/
Family member told us
"At entrance the bins were overflowing with bags, in the COVID period, and managers could've done much more to control this. I'm not sure if it's addressed even now because they are still regularly there"
120/
During our inspection we did not see overflowing bins, and the service's action plan stated a bin store compound would be developed.
[I just can't]
121/
[I just can't]
121/
A 'read and sign' process informed staff about important updates.
We consistently found not all staff had signed to confirm they read updates and there was no evidence gaps had been addressed.
A 'read and sign' document from March 2021 had been signed by 6 of 15 staff
122/
We consistently found not all staff had signed to confirm they read updates and there was no evidence gaps had been addressed.
A 'read and sign' document from March 2021 had been signed by 6 of 15 staff
122/
We observed the use of 'tick sheets' to document behaviours.
Staff ticked against handwritten headings such as 'hit staff', 'punching and 'screams'.
Tick sheets recorded the date of incidents with no further information.
123/
Staff ticked against handwritten headings such as 'hit staff', 'punching and 'screams'.
Tick sheets recorded the date of incidents with no further information.
123/
We were advised the 'tick sheets' had been introduced by a visiting professional as an addition to the service's own internal processes for incident reporting.
124/
124/
We crossed referenced tick sheets with incident forms and found these had not been completed for several 'ticked' incidents.
This meant there was no evidence these incidents had been reviewed to explore antecedents and take steps to prevent reoccurrence.
125/
This meant there was no evidence these incidents had been reviewed to explore antecedents and take steps to prevent reoccurrence.
125/
Where incident forms were completed, there was no evidence of management oversight of individual incidents to assess or mitigate the risk of harm to people, staff and others.
126/
126/
There was a summary log to note incidents for each person, however the column entitled 'action planned' was frequently left blank.
[Course it was; because no-one knows what they're doing or why. State of it]
127/
[Course it was; because no-one knows what they're doing or why. State of it]
127/
There was no evidence in the accident/incident file, complaints file or safeguarding file about how the service audited or analysed incident reports over time, to identify potential themes and strategies or lessons learnt to prevent and reduce reoccurrences.
128/
128/
23 March 2022 manager advised an incident had occurred where a person was left unattended in a bath.
13 April 2022 nominated individual explained was no documentation about the incident and the staff member was away, meaning it wasn't possible to complete an investigation.
129/
13 April 2022 nominated individual explained was no documentation about the incident and the staff member was away, meaning it wasn't possible to complete an investigation.
129/
The person's risk assessment, which was undated, identified hazards such as slipping when getting in and out of the bath.
It stated, 'check water temperature' and 'never leave [person] unsupervised'.
130/
It stated, 'check water temperature' and 'never leave [person] unsupervised'.
130/
A staff member told us the person must never be left alone in the bath as there was a risk of the person 'opening' the taps and scalding himself.
This was not identified as a hazard in the risk assessment.
[In a service where staff can't identify who has epilepsy too]
131/
This was not identified as a hazard in the risk assessment.
[In a service where staff can't identify who has epilepsy too]
131/
Incidents logged 7 April 2022, 15 April 2022 and two occasions in June 2021 where a person had overturned a table.
There was no evidence of management oversight of any of these incidents and the care consultant advised staff hadn't discussed the recent incidents with them.
132/
There was no evidence of management oversight of any of these incidents and the care consultant advised staff hadn't discussed the recent incidents with them.
132/
[What is the point of this care consultant exactly?]
The person's care plan and risk assessments did not refer to the behaviour, meaning there was no written guidance to advise staff how to mitigate risk.
133/
The person's care plan and risk assessments did not refer to the behaviour, meaning there was no written guidance to advise staff how to mitigate risk.
133/
Risks to people were not clearly identified and managed, and systems were not operated to promote learning from incidents to mitigate risks to people.
This was a breach of Regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities)
134/
This was a breach of Regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities)
134/
The provider had an action plan in place.
We were advised the care consultant would review the previous three months incidents to identify potential safeguarding concerns.
The care consultant advised monthly analysis of accidents and incidents was due to commence.
135/
We were advised the care consultant would review the previous three months incidents to identify potential safeguarding concerns.
The care consultant advised monthly analysis of accidents and incidents was due to commence.
135/
The service had purchased a new suite of policies, meaning an updated accidents and incidents policy would be implemented.
Following our inspection the provider advised the 'tick sheets' had been subject to further investigation...
136/
Following our inspection the provider advised the 'tick sheets' had been subject to further investigation...
136/
...we were informed staff could not recall two 'ticked' incidents where people had been allegedly hit by another person using the service, and it was therefore believed the ticks were in the wrong box.
The 'tick sheets' were subsequently withdrawn.
[No words]
137/
The 'tick sheets' were subsequently withdrawn.
[No words]
137/
The service did not ensure people were supported by staff who had been subject to appropriate recruitment checks.
The service did not seek applicants' full employment history, and we found no evidence gaps in employment history had been explored.
138/
The service did not seek applicants' full employment history, and we found no evidence gaps in employment history had been explored.
138/
One file did not include an application form and two application forms were partially completed.
One staff member's proof of address did not match the photographic ID they had provided.
[Apathetic at application and ever since. Partially completed application forms]
139/
One staff member's proof of address did not match the photographic ID they had provided.
[Apathetic at application and ever since. Partially completed application forms]
139/
We found one staff member's references obtained in 2017 and another staff member's references obtained in 2018 had not been verified until 2022.
[Hmmm. Wouldn't be because @CareQualityComm had cracked down on their neighbouring service in 2022 could it?]
140/
[Hmmm. Wouldn't be because @CareQualityComm had cracked down on their neighbouring service in 2022 could it?]
140/
References were marked with a handwritten note 'verified', without any details about how this was achieved.
[How can anyone think this is acceptable? Clearly no consideration of the Duty of Candour in this place either]
141/
[How can anyone think this is acceptable? Clearly no consideration of the Duty of Candour in this place either]
141/
Provider's recruitment policy stated min of 2 references were required, if at all poss. based on previous employment, and if referee was personal, if poss. have some standing in the community, and if in doubt to seek 3 references.
The policy was inconsistently followed.
142/
The policy was inconsistently followed.
142/
There were no risk assessments or written explanations about decisions to appoint staff without appropriate references.
The provider's interview process was not designed to demonstrate the candidate's skills to support people with a learning disability.
143/
The provider's interview process was not designed to demonstrate the candidate's skills to support people with a learning disability.
143/
The questionnaire contained basic questions such as, "What difficulties might someone with autism have?" but did not ask questions about person-centred care, relevant legislation or equality values.
One staff file did not contain an interview record.
144/
One staff file did not contain an interview record.
144/
Where another applicant indicated they had no experience, and only partially met criteria for nine of the interview questions, there was no explanation as to why they were recruited.
[Complete absence of care from day one]
145/
[Complete absence of care from day one]
145/
For three staff we found a DBS number handwritten onto the staff member's file, meaning we could not establish the date of the check, whether the DBS barred list had been checked, and whether a manager had checked the certificates were satisfactory.
146/
146/
Nominated individual explained original DBS certificates had been destroyed after service was advised they could not retain copies, however it appeared this had been inconsistently implemented, as some DBS certificates were found in a filing cupboard during our inspection.
147/
147/
One DBS check showed previous convictions.
The staff member commenced work in 2014 and the risk assessment on file was dated 2017, last reviewed in 2018.
The risk assessment contained inaccuracies in relation to references.
148/
The staff member commenced work in 2014 and the risk assessment on file was dated 2017, last reviewed in 2018.
The risk assessment contained inaccuracies in relation to references.
148/
The staff member regularly worked without management supervision and no supervision records were accessible at the time of our visit.
The staff member had failed to fully complete the job application form and the interview record advised they had no knowledge of autism.
149/
The staff member had failed to fully complete the job application form and the interview record advised they had no knowledge of autism.
149/
We were not assured a robust recruitment process had been followed.
We reviewed profiles for agency staff who had recently worked at the service.
[It won't surprise anyone reading this that things weren't better there either]
150/
We reviewed profiles for agency staff who had recently worked at the service.
[It won't surprise anyone reading this that things weren't better there either]
150/
Some of the profiles did not contain DBS numbers and none of the profiles indicated staff had experience supporting people with learning disabilities.
[None of them]
151/
[None of them]
151/
We spoke with one regular agency staff who confirmed they had not received training about learning disabilities, autism, or supporting people's behaviours.
We were not assured the suitability of agency staff had been sufficiently checked prior to work.
152/
We were not assured the suitability of agency staff had been sufficiently checked prior to work.
152/
There was no evidence the service had considered applying for overseas criminal checks where a candidate's application indicated their previous employment 2013-2018 was overseas.
153/
153/
Recruitment procedures were not always operated effectively to ensure staff employed were of good character or suitable for the role.
This was breach of Regulation 19 (Fit and proper persons employed) of the Health and Social Care Act 2008 (Regulated Activities) Regs 2014
154/
This was breach of Regulation 19 (Fit and proper persons employed) of the Health and Social Care Act 2008 (Regulated Activities) Regs 2014
154/
The director explained staff funding levels were agreed with commissioning bodies when people moved in and described the information as "quite historical".
[Who's responsibility is it to not ensure regular reviews? Such apathy at every level]
155/
[Who's responsibility is it to not ensure regular reviews? Such apathy at every level]
155/
Director confirmed formal systems, such as a dependency tool, had not been used to regularly review whether funding provided sufficient staffing.
They explained staff ratios had been agreed with local authority when people moved to service, or as people's needs changed.
156/
They explained staff ratios had been agreed with local authority when people moved to service, or as people's needs changed.
156/
The nominated individual told us they had contacted commissioners to request a funding review.
Staff described an impact to people when staffing levels weren't maintained.
157/
Staff described an impact to people when staffing levels weren't maintained.
157/
A staff member explained when the service was short staffed activities couldn't take place and stated three people would be "left for [the] duration of [the] shift" because two people needed "a lot of time and attention".
158/
158/
Recent rotas showed were sometimes less staff working between 7-9am due to staff contracted hours.
Staff member described working between 7-9am with one agency worker which they stated was insufficient... breaks and cleaning cld not always take place when short staffed.
159/
Staff member described working between 7-9am with one agency worker which they stated was insufficient... breaks and cleaning cld not always take place when short staffed.
159/
Lack of continuity for staff deployment where ppl required 1-1 support.
Staff member supporting a person told us they wld likely support individual either for 10 mins, 20 mins or one hour, adding someone else wld come after, explaining it "depends on how the shift goes".
160/
Staff member supporting a person told us they wld likely support individual either for 10 mins, 20 mins or one hour, adding someone else wld come after, explaining it "depends on how the shift goes".
160/
Whilst in some cases people can benefit from a change of staff face, for example following an incident of distress, we were concerned the inconsistent deployment of staff could have caused unnecessary uncertainty and did not help people to plan a structured day.
161/
161/
Rotas assigned staff to provide 1-1 support, in practice staff agreed their deployment during shift.
Acting team leader explained staff spoke amongst themselves to agree duties, taking into consideration... who completed personal care tasks day before and who would cook.
162/
Acting team leader explained staff spoke amongst themselves to agree duties, taking into consideration... who completed personal care tasks day before and who would cook.
162/
We found no evidence staff were matched with people based on their skills.
Staff without Makaton skills supported people who used Makaton (a type of sign language).
One person with complex needs was frequently supported by agency staff.
[All about staff convenience]
163/
Staff without Makaton skills supported people who used Makaton (a type of sign language).
One person with complex needs was frequently supported by agency staff.
[All about staff convenience]
163/
We spoke with two agency workers who told us they had not received training in relation to autism or supporting people's behaviours.
We were concerned this arrangement was unsafe.
164/
We were concerned this arrangement was unsafe.
164/
Nominated individual explained rotas had been identified as a concern, and it was believed a culture had developed where there was an expectation female staff would cook and clean, meaning skilled female staff were diverted to domestic duties.
[It was believed... no words]
165/
[It was believed... no words]
165/
We were not assured enough suitably qualified, competent and experienced staff were deployed to safely meet people's needs.
This was a breach of Regulation 18 (Staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
166/
This was a breach of Regulation 18 (Staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
166/
The nominated individual explained a staff meeting was planned to speak with staff about the importance of following rotas, or documenting a rationale where a change of staff deployment was necessary.
[Planned to... nominated individual... always in the future]
167/
[Planned to... nominated individual... always in the future]
167/
We were advised the provider was committed to changing the team culture to ensure equity of duties for female staff.
[This place is toxic. Needs shut down. Never mind conversations, consultancy and purchased suites of policies. Get people out of there]
168/
[This place is toxic. Needs shut down. Never mind conversations, consultancy and purchased suites of policies. Get people out of there]
168/
[Effective - inadequate]
At the last inspection this key question was rated as Good. At this inspection this key question has now deteriorated to Inadequate.
This meant there were widespread and significant shortfalls in people's care, support and outcomes.
169/
At the last inspection this key question was rated as Good. At this inspection this key question has now deteriorated to Inadequate.
This meant there were widespread and significant shortfalls in people's care, support and outcomes.
169/
We reviewed national malnutrition screening records for five people.
Staff failed to enter the information required on the form in order to assess whether people would benefit from a dietitian referral.
[Such blatant disregard for the basics]
170/
Staff failed to enter the information required on the form in order to assess whether people would benefit from a dietitian referral.
[Such blatant disregard for the basics]
170/
One person's behaviour plan stated the service should display a picture menu board for the day's meal.
There was no menu accessible to people in the dining room.
[Course not. Why communicate, forewarn and allow someone to prepare themselves for their meal]
171/
There was no menu accessible to people in the dining room.
[Course not. Why communicate, forewarn and allow someone to prepare themselves for their meal]
171/
We consistently observed, and a staff member confirmed, everyone consumed the same food, with adaptations for one person's food intolerance and another person's soft food diet.
Menus did not offer a daily choice of main meals, snacks or desserts.
172/
Menus did not offer a daily choice of main meals, snacks or desserts.
172/
A staff member told us when ordering food and developing the menu they "sometimes" asked what people wanted to eat.
[Sometimes]
People were not offered day to day choices.
At one meal a staff member served everyone orange squash, without asking what people would prefer.
173/
[Sometimes]
People were not offered day to day choices.
At one meal a staff member served everyone orange squash, without asking what people would prefer.
173/
A person asked twice for coffee, staff member first responded, "Later" and then, "Finish this first and coffee later."
On another occasion everyone was served with curry followed by yoghurts.
One person asked for jelly but was told they had already been given dessert
174/
On another occasion everyone was served with curry followed by yoghurts.
One person asked for jelly but was told they had already been given dessert
174/
Observations showed, and staff feedback confirmed, everyone's breakfasts were prepared at the same time.
One person got up later and on two occasions we observed their breakfast left pre-prepared in the kitchen.
175/
One person got up later and on two occasions we observed their breakfast left pre-prepared in the kitchen.
175/
A piece of toast and jam was covered in cling film, which was cold to the touch, and this was taken to the person to eat.
[This is so lazy. Non-care. How hard is it to make fresh toast? All about staff convenience, nothing about living a life in your own home]
176/
[This is so lazy. Non-care. How hard is it to make fresh toast? All about staff convenience, nothing about living a life in your own home]
176/
During a visit we observed people requested drinks and staff responded to this.
There had not been consideration about how people could access drinks for themselves, without having to ask staff, such as a water dispenser.
177/
There had not been consideration about how people could access drinks for themselves, without having to ask staff, such as a water dispenser.
177/
One person required minced and moist food following a review by speech and language therapy (SALT).
SALT guidelines were included within the care folder, however the care plan contained contradictory information which could have placed the person at risk.
178/
SALT guidelines were included within the care folder, however the care plan contained contradictory information which could have placed the person at risk.
178/
A photo page of the person's favourite foods included a standard sandwich, standard biscuit and standard portion of sausages and mash.
[This total apathy is so infuriating. Refer to SALT, then ignore whatever they say, don't even get the basics right]
179/
[This total apathy is so infuriating. Refer to SALT, then ignore whatever they say, don't even get the basics right]
179/
Another person's care plan stated they could feed themselves and required a plate guard.
The care plan instructed staff to split the person's meal onto two plates to avoid them finishing quickly and disrupting others.
180/
The care plan instructed staff to split the person's meal onto two plates to avoid them finishing quickly and disrupting others.
180/
The care plan did not state what utensils were required.
Throughout our inspection we observed staff did not follow the care plan.
One meal was served in a single bowl and staff used a dessert spoon to 'hand over hand' place food into the person's mouth.
181/
Throughout our inspection we observed staff did not follow the care plan.
One meal was served in a single bowl and staff used a dessert spoon to 'hand over hand' place food into the person's mouth.
181/
On another occasion a single plate with plate guard was served.
The person finished quickly and disturbed others who were still eating.
[Almost carbon copy of what the care plan had already warned would happen, but care plans aren't actually for following are they?]
182/
The person finished quickly and disturbed others who were still eating.
[Almost carbon copy of what the care plan had already warned would happen, but care plans aren't actually for following are they?]
182/
On a third occasion the person was served chopped food without a plate guard.
They struggled to eat with a teaspoon and staff repeatedly removed their hand to put food onto the spoon.
183/
They struggled to eat with a teaspoon and staff repeatedly removed their hand to put food onto the spoon.
183/
The person's risk document identified the hazard,
"[Person] can so quickly and forget to chew and may choke".
This did not make sense as the word 'eat' was omitted.
There was no reference to or evidence of a referral to SALT to mitigate this risk.
184/
"[Person] can so quickly and forget to chew and may choke".
This did not make sense as the word 'eat' was omitted.
There was no reference to or evidence of a referral to SALT to mitigate this risk.
184/
A staff member explained they would tell the person to slow down, however said,
"depends on mood…if will listen"
and described the person
"coughing and spluttering".
After our visit we were advised a SALT referral had been verbally discussed with the GP.
[No words]
185/
"depends on mood…if will listen"
and described the person
"coughing and spluttering".
After our visit we were advised a SALT referral had been verbally discussed with the GP.
[No words]
185/
Two other people had identified risks of choking.
Within care plans we found no evidence the service had sought guidance from SALT or other professionals when designing risk reduction measures.
186/
Within care plans we found no evidence the service had sought guidance from SALT or other professionals when designing risk reduction measures.
186/
One person's care plan did not include a risk assessment in relation to their risk of choking.
The second person's care plan included an undated risk assessment which stated the person was at high risk of choking.
187/
The second person's care plan included an undated risk assessment which stated the person was at high risk of choking.
187/
There was no evidence the assessment had been subject to regular review and there was no rationale to evidence how the level of risk was determined.
188/
188/
The service did not consistently identify or meet people's nutrition or hydration needs.
This was a breach of Regulation 14 (Meeting nutritional and hydration needs) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
189/
This was a breach of Regulation 14 (Meeting nutritional and hydration needs) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
189/
People's care records and the support staff provided did not consistently reflect evidence-based guidance and best practice.
190/
190/
People's care records contained behaviour support plans. Some were undated and another person's behaviour support plan was dated 1 January 2020.
[OK,
1) Come on, who is writing a PBS plan on New Years Day?
2) Why no review in 2yrs 3mths?]
191/
[OK,
1) Come on, who is writing a PBS plan on New Years Day?
2) Why no review in 2yrs 3mths?]
191/
Four people's care records contained no evidence of how behaviours had been assessed, who had been involved in these assessments, or whether reviews of the effectiveness of the plans had taken place.
There was limited evidence of how the service assessed sensory needs.
192/
There was limited evidence of how the service assessed sensory needs.
192/
One person's behaviour support plan noted noise as a trigger.
Another person's care plan noted they did not like loud noises.
A third person's care plan highlighted noise could cause them to become anxious, which we observed during our visit.
193/
Another person's care plan noted they did not like loud noises.
A third person's care plan highlighted noise could cause them to become anxious, which we observed during our visit.
193/
One person expressed themselves through loud vocalising and banging.
There was no evidence within care plans as to how ongoing impact of noise on ppl's wellbeing had been considered, including whether people's needs had been assessed as being compatible with one another.
194/
There was no evidence within care plans as to how ongoing impact of noise on ppl's wellbeing had been considered, including whether people's needs had been assessed as being compatible with one another.
194/
Care assessments had not holistically explored people's sexual health and relationship needs.
One person's care plan did not contain information about why they received contraceptive medicine.
Staff explained two people separately needed privacy to meet their needs.
195/
One person's care plan did not contain information about why they received contraceptive medicine.
Staff explained two people separately needed privacy to meet their needs.
195/
One person's care plan did not make reference to this, and another person's care plan included this within a behaviour support plan alongside a description of "sexual inappropriate behaviours".
[No words. It's as tho ppl are so pathologised they're not seen as human]
196/
[No words. It's as tho ppl are so pathologised they're not seen as human]
196/
Care records did not include oral health assessments.
Care plans contained basic information such as whether the person needed full support to brush their teeth, without giving details about the type of brush or toothpaste used.
197/
Care plans contained basic information such as whether the person needed full support to brush their teeth, without giving details about the type of brush or toothpaste used.
197/
One person's teeth brushing record stated they were 'uncooperative' on ten occasions in the morning between 1 and 15 April 2022.
There were several gaps in the PM column.
Care plans were not updated to include recommendations given by a dentist on 4 April 2022.
198/
There were several gaps in the PM column.
Care plans were not updated to include recommendations given by a dentist on 4 April 2022.
198/
[This makes me so sad, and more than a little mad. Remember Rachel Johnston, she died after surgery to remove all her teeth georgejulian.co.uk/inquests/rache… everyone was directing their outrage at the dentist, not those who were meant to support her oral hygiene in the first place]
199/
199/
The service did not ensure that care plans fully identified or met people's needs.
This was a breach of Regulation 9 (Person-centred care) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
200/
This was a breach of Regulation 9 (Person-centred care) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
200/
The service's environment was poorly maintained.
Paintwork appeared damaged, dirty, damp and mouldy in places.
One wall had cracked plaster work and another wall had a large area of plaster board missing, exposing pipework within the wall.
201/
Paintwork appeared damaged, dirty, damp and mouldy in places.
One wall had cracked plaster work and another wall had a large area of plaster board missing, exposing pipework within the wall.
201/
Maintenance issues presented health and safety risks.
One bedroom door was propped open with a cupboard and a staff member told us the magnetic door release mechanism had not worked for a few months.
202/
One bedroom door was propped open with a cupboard and a staff member told us the magnetic door release mechanism had not worked for a few months.
202/
Bathrooms were in a poor state of repair.
There were broken cupboards, one toilet had a broken seat and another had a broken flush button.
We opened the cupboard drawer in one person's bathroom and found this had a dirty, cracked surface.
203/
There were broken cupboards, one toilet had a broken seat and another had a broken flush button.
We opened the cupboard drawer in one person's bathroom and found this had a dirty, cracked surface.
203/
We observed numerous uncovered radiators, some of which were very hot to the touch. One person was observed sitting on an uncovered radiator in the hallway, which was warm but not hot enough to cause a burn. However, there was a potential risk people could sustain burns.
204/
204/
We were advised one person benefited from looking at lights on a sensory machine.
This was not observed working throughout our inspection and information from the provider confirmed it was broken.
[Non-lives, non-care, in a mouldy, shabby, dangerous environment]
205/
This was not observed working throughout our inspection and information from the provider confirmed it was broken.
[Non-lives, non-care, in a mouldy, shabby, dangerous environment]
205/
We observed no similar sensory equipment available for the person's use. There was no evidence of how the rest of the environment had been designed to meet people's specific sensory needs such as lighting, sound and touch.
206/
206/
We identified concerns regarding the safety and security of rear doors.
The dining room door was secured with two simple bolts, one top and bottom, and a staff member explained the key to the lock had been missing for some time.
207/
The dining room door was secured with two simple bolts, one top and bottom, and a staff member explained the key to the lock had been missing for some time.
207/
The conservatory door was found locked, the door was heavily damaged, with part of the door having fallen off into the garden.
The garden was not suitable for the purpose it was being used.
208/
The garden was not suitable for the purpose it was being used.
208/
The garden contained holes created by wild animals, and was generally uneven throughout which we were advised was due to moles.
[Sounds like the moles had a better life than the people living there]
209/
[Sounds like the moles had a better life than the people living there]
209/
We observed one person with mobility difficulties needed constant staff support and struggled to negotiate the uneven ground to kick a football.
[What's the odds that this garden use was only a performance for CQC's benefit in the first place?]
210/
[What's the odds that this garden use was only a performance for CQC's benefit in the first place?]
210/
A staff member explained another person with visual impairment could not use the garden without holding onto staff as they could not see the mole hills.
The maintenance book was poorly maintained.
211/
The maintenance book was poorly maintained.
211/
Several maintenance concerns had been logged by staff for the period of April 2020 onwards, however the columns to be completed with actions and completion dates had not been updated, meaning it was unclear how quickly maintenance issues were attended to.
212/
212/
The service was not always clean, well maintained or secure. This was a breach of Regulation 15 (Premises and equipment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
213/
213/
Care plans included an undated 'Health support plan', containing a list of diagnoses, prescribed medicines and allergies. There was no additional information within the health plans, such as the impact of diagnoses or the purpose of prescribed medicines.
214/
214/
Some care plans contained info sheets, however info was not personalised.
One person's info sheet about mood disorders described conditions including postpartum depression, seasonal affective disorder, psychotic depression and bi-polar.
[Tombola encyclopedia non-care]
215/
One person's info sheet about mood disorders described conditions including postpartum depression, seasonal affective disorder, psychotic depression and bi-polar.
[Tombola encyclopedia non-care]
215/
Each person using the service had a 'health passport' which can be shared when a person requires inpatient treatment.
[I've been banging on about hospital passports for years georgejulian.co.uk/2020/04/03/hos… So many limitations, and potential dangers attached]
216/
[I've been banging on about hospital passports for years georgejulian.co.uk/2020/04/03/hos… So many limitations, and potential dangers attached]
216/
Health passports were partially completed and there was no evidence they had been regularly reviewed to ensure the information could be relied upon by health professionals.
Some entries within health passports were last updated in 2017.
[Partial, stale, dangerous info]
217/
Some entries within health passports were last updated in 2017.
[Partial, stale, dangerous info]
217/
One person's records contained an appointment letter for breast screening.
A handwritten note stated, 'Appointment cancelled, best interest.'
There was no information to explain how the decision was reached or whether a medical professional was involved in the decision.
218/
A handwritten note stated, 'Appointment cancelled, best interest.'
There was no information to explain how the decision was reached or whether a medical professional was involved in the decision.
218/
[This is outrageous, especially given how many learning disabled people die from late diagnosed, or undiagnosed, cancer.
Screening is crucial for a group already at higher risk of health inequality]
219/
Screening is crucial for a group already at higher risk of health inequality]
219/
The person's care plan contained no information about any checks or visual observations required in the absence of breast screening to detect changes to the person's breasts.
220/
220/
Records showed telemedicine, a digital healthcare system, hadn't been used since 29 January 2021.
We were informed the password for the system was unknown.
[Lost password. Lost health. How long before lost lives? Non lives.]
221/
We were informed the password for the system was unknown.
[Lost password. Lost health. How long before lost lives? Non lives.]
221/
We reviewed an incident report, dated 9 March 2022, where a person was observed with red marks after a fall on the stairs.
There was no evidence staff had sought medical advice or provided a rationale as to why this was not required.
222/
There was no evidence staff had sought medical advice or provided a rationale as to why this was not required.
222/
We reviewed report for another person's fall from a chair, 22 June 2021.
No evidence medical advice had been sought.
Report stated person was, "alright, had no injuries" but no detail was added to explain how the person, who communicated non-verbally, had been checked.
223/
No evidence medical advice had been sought.
Report stated person was, "alright, had no injuries" but no detail was added to explain how the person, who communicated non-verbally, had been checked.
223/
There was no information about people's annual learning disability health checks in their care records.
Some people had not accessed dental care or chiropody since prior to the pandemic. The service could not confirm when some people had last seen an optician.
224/
Some people had not accessed dental care or chiropody since prior to the pandemic. The service could not confirm when some people had last seen an optician.
224/
Although routine appointments were impacted by lockdown restrictions, the service had failed to provide timely support to resume appointments.
225/
225/
A family member explained one person had last seen a dentist around two to three years ago and experienced bleeding due to gum disease.
Staff confirmed they had noticed blood.
226/
Staff confirmed they had noticed blood.
226/
The service could not confirm the date the person last saw a dentist, although a staff member advised this was prior to the pandemic.
[Imagine being so apathetic with someone's health, their life, their happiness. Grim]
227/
[Imagine being so apathetic with someone's health, their life, their happiness. Grim]
227/
The person's April 2022 teeth brushing record showed multiple gaps without explanation.
[You know what gets me about this situation too...
We're often told how learning disabled people are complex, you remember the last time you had tooth ache? Basics not checked out]
228/
[You know what gets me about this situation too...
We're often told how learning disabled people are complex, you remember the last time you had tooth ache? Basics not checked out]
228/
Staff had not implemented guidance from the community learning disability team.
A letter, dated 18 August 2021, asked staff to complete a sleep diary for two weeks due to concerns about a person's sleep pattern.
There was no evidence of this being completed on file.
229/
A letter, dated 18 August 2021, asked staff to complete a sleep diary for two weeks due to concerns about a person's sleep pattern.
There was no evidence of this being completed on file.
229/
There was no information in the person's care plans or risk assessments about how staff should promote sleep to improve wellbeing.
During our night visit staff told us the person only slept for approximately three or four hours.
[Night visit 👊]
230/
During our night visit staff told us the person only slept for approximately three or four hours.
[Night visit 👊]
230/
Daily records for 14, 15 and 16 April 2022 showed the person slept for about 5 hrs per night.
[Since Mum died I've rarely had >5hrs sleep a night due to her ageing, senile, incontinent dog. I can tell you its murder on the body, mind and soul.
Here, no care given at all]
231/
[Since Mum died I've rarely had >5hrs sleep a night due to her ageing, senile, incontinent dog. I can tell you its murder on the body, mind and soul.
Here, no care given at all]
231/
The letter also stated staff should create a routine for supporting with continence pad changes as this caused the person anxiety.
However, we found there was no information about a routine in the person's care plan.
232/
However, we found there was no information about a routine in the person's care plan.
232/
On one occasion we observed the person was wet at 10.05am and remained wet at 10.16am.
At 10.28am we heard sounds of distress and observed the person had become agitated.
After the incident we asked staff about potential triggers.
233/
At 10.28am we heard sounds of distress and observed the person had become agitated.
After the incident we asked staff about potential triggers.
233/
A staff member explained the person had started to shout after staff tried to support the person to go the bathroom.
234/
234/
The service did not consistently support people to access healthcare services and support to meet their needs.
This was a breach of Regulation 9 (Person-centred care) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
235/
This was a breach of Regulation 9 (Person-centred care) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
235/
Records showed training in relation to MCA was in date for only 4 of 15 staff, and training in relation to DoLS was in date for 5 staff at the start of our inspection.
236/
236/
Training for other staff was either incomplete or overdue refresher which training matrix confirmed shd be repeated yearly.
At start of our inspection no one using the service had an authorised DoLS in place and everyone was subject to restrictions due to potential risks.
237/
At start of our inspection no one using the service had an authorised DoLS in place and everyone was subject to restrictions due to potential risks.
237/
Records showed four people's DoLS authorisations had expired between March and April 2018.
The service had failed to re-apply for DoLS authorisations until October 2018, meaning there had been a significant delay in applications.
238/
The service had failed to re-apply for DoLS authorisations until October 2018, meaning there had been a significant delay in applications.
238/
There was no evidence the service had sought verification where relatives indicated they held legal authority to assist with decision making.
239/
239/
After our visit the nominated individual confirmed the service held no evidence of deputyship or power of attorney relating to two individuals and told us enquiries were being made to seek verification.
240/
240/
People's records contained a form entitled 'Photography and video consent form' which ticked 'Yes' to the questions 'Can I take your photo?', 'Can I video you?' and 'Can I show it to other people?'. Care records contained photos of people partaking in activities.
241/
241/
The questions were accompanied by a statement,
"I enjoy when people take my photographs and enjoy looking at them too. Staff observed my reaction to photographs and has taken this view."
242/
"I enjoy when people take my photographs and enjoy looking at them too. Staff observed my reaction to photographs and has taken this view."
242/
The form did not evidence a MCA process had taken place, such as exploring whether people understood who would have access to their image.
[Providers wanting photos for their publicity material no doubt; cant sort basics, but when it comes to having photos to use...]
243/
[Providers wanting photos for their publicity material no doubt; cant sort basics, but when it comes to having photos to use...]
243/
MCA records did not appropriately document how representatives were consulted.
For example, an MCA assessment and best interest record dated 13 September 2021, for a decision to reside at the service, stated family input had been considered and they agreed...
244/
For example, an MCA assessment and best interest record dated 13 September 2021, for a decision to reside at the service, stated family input had been considered and they agreed...
244/
...but did not provide any specific information about their views.
The assessment was only signed by the registered manager and deputy manager.
The best interest documents for three other people with family involvement were also unsigned by families.
[Hmmmm]
245/
The assessment was only signed by the registered manager and deputy manager.
The best interest documents for three other people with family involvement were also unsigned by families.
[Hmmmm]
245/
Several MCA and best interests decisions were completed on 13 September 2021 involving six service users, covering topics from decisions to reside at Penley Grange, consent for COVID-19 testing, management of finances and consent for medicines.
246/
246/
One person's best interests decision referred to a different person using the service. The MCA and best interest decisions for 3 female service users for COVID-19 testing, referred to them using male pronouns in same four places using same wording.
[Copy and paste care]
247/
[Copy and paste care]
247/
One decision stated "[Person's] family are happy for [person's name] to have regular testing of the COVID-19", however the person had no family involvement.
Our findings meant we were not assured assessments had been completed in accordance with legislation.
248/
Our findings meant we were not assured assessments had been completed in accordance with legislation.
248/
Decision specific MCAs had not been recorded for additional restrictions, such as one person's recent use of a baby monitor, which had been used by night staff to listen for seizure activity.
[Since an early visit where CQC pointed out someone had epilepsy no doubt]
249/
[Since an early visit where CQC pointed out someone had epilepsy no doubt]
249/
[That's before I even get into whether using a baby monitor is the best solution in the first place, given there are many sophisticated technological approaches to monitoring seizures at night nowadays]
250/
250/
One person's MCA decision in relation to their finances had not been reviewed since 2019 and the MCA decision relating to their care and accommodation at Penley Grange had not been reviewed since 2020.
Both MCA forms stated the decisions should be reviewed annually.
251/
Both MCA forms stated the decisions should be reviewed annually.
251/
Effective systems were not operated to ensure the service worked in accordance with the requirements of the Mental Capacity Act 2005 and associated code of practice.
This was a breach of Regulation 11 (Need for consent) of the Health and Social Care Act 2008
252/
This was a breach of Regulation 11 (Need for consent) of the Health and Social Care Act 2008
252/
Staff did not always receive appropriate training and ongoing support to benefit people using the service.
Numerous training gaps and expired training in topics such as moving and handling, person-centred care, first aid awareness and health and safety.
253/
Numerous training gaps and expired training in topics such as moving and handling, person-centred care, first aid awareness and health and safety.
253/
Induction processes were reliant on e-learning to equip staff with knowledge and skills. We found the 3 newest staff members had not completed any e-learning.
Another staff member employed since September 2021 had only completed 1 of 20 assigned e-learning modules.
254/
Another staff member employed since September 2021 had only completed 1 of 20 assigned e-learning modules.
254/
Induction systems failed to assess whether staff demonstrated knowledge gained via e-learning.
The induction records for one staff member employed since 2018 were only partially completed and they had not been signed off as competent.
255/
The induction records for one staff member employed since 2018 were only partially completed and they had not been signed off as competent.
255/
We found no evidence staff new to care had been supported to gain the Care Certificate.
The provider's policy and procedure for physical interventions referred to a particular training course and technique, which was not provided by the service.
256/
The provider's policy and procedure for physical interventions referred to a particular training course and technique, which was not provided by the service.
256/
Staff training about specialist needs was inconsistent.
At the time of our inspection only two members of staff had up-to-date epilepsy training.
[1 in 4 learning disabled people have epilepsy, some suggest 1 in 3. Only 2 staff knew about it]
257/
At the time of our inspection only two members of staff had up-to-date epilepsy training.
[1 in 4 learning disabled people have epilepsy, some suggest 1 in 3. Only 2 staff knew about it]
257/
A relative raised concern regarding staff training, advising "I don't think all of them have training, as it's mainly the temporary staff who are not using the best of actions or behaviours towards [relative], and you only make [relative] behaviour worse if you don't...
258/
258/
...follow what you should do. Even the social worker said that strategies were not being followed, and that means training."
We were advised an agency induction process was in place, however the last written agency induction record accessible was dated 26 September 2018.
259/
We were advised an agency induction process was in place, however the last written agency induction record accessible was dated 26 September 2018.
259/
An agency worker confirmed they had not read care plans and had been given a verbal handover.
They were not aware of the diagnosis or the contents of the behaviour support plan for the person they supported.
260/
They were not aware of the diagnosis or the contents of the behaviour support plan for the person they supported.
260/
They advised, "Have been told, do what they do, sometimes they bribe with biscuit or will put music on." This was not in line with the person's behaviour plan.
[PBS is so dangerous, misunderstood PBS even more so]
261/
[PBS is so dangerous, misunderstood PBS even more so]
261/
Staff supervisions had been completed at inconsistent and infrequent intervals by the previous registered manager and deputy manager. We found no evidence of staff appraisals.
262/
262/
We could not locate supervision records for six members of staff and the on-site care consultant confirmed they had checked and had not been able to locate these records.
263/
263/
The service did not always ensure people were supported by suitably qualified, competent, skilled and experienced staff.
This was a breach of Regulation 18 (Staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
264/
This was a breach of Regulation 18 (Staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
264/
[Caring - requires improvement]
At last inspection this key question was rated as Good. At this inspection this key question has now deteriorated to Requires improvement. This meant people did not always feel well-supported, cared for or treated with dignity and respect.
265/
At last inspection this key question was rated as Good. At this inspection this key question has now deteriorated to Requires improvement. This meant people did not always feel well-supported, cared for or treated with dignity and respect.
265/
We found the level of interaction and engagement staff members provided to people was mixed.
We observed an agency staff member supporting a person who was able to feed themselves.
266/
We observed an agency staff member supporting a person who was able to feed themselves.
266/
The agency staff held a biscuit between their fingers, and said to the person, "Open your mouth, open your mouth", and with a chuckle, they moved the biscuit away.
267/
267/
Whilst we could not determine the agency staff's intention, the interaction did not promote person's independence or treat them with respect, as we were advised acting team leader had already broken the biscuit into small pieces to make it safe for the person to consume.
268/
268/
The agency staff later used a loud tone, saying "sit down".
During a meal three staff stood around the person's table, with the agency staff member leaning over the person during their meal.
269/
During a meal three staff stood around the person's table, with the agency staff member leaning over the person during their meal.
269/
Staff interactions lacked warmth, such as using a frustrated tone to instruct the person, "Finish your food properly".
[In front of @CareQualityComm inspectors]
During and after one mealtime we observed a person eating their lunch had food around their mouth.
270/
[In front of @CareQualityComm inspectors]
During and after one mealtime we observed a person eating their lunch had food around their mouth.
270/
A staff member was sat next to the person watching, but did not offer any support to the person to wipe their mouth.
On another occasion a person finished eating and walked around the dining room.
271/
On another occasion a person finished eating and walked around the dining room.
271/
A staff member approached them, and without interacting with the person, proceeded to wipe the person's mouth. This was not dignified or respectful.
[Imagine if someone did that to you]
272/
[Imagine if someone did that to you]
272/
We observed occasions where staff did not respect people's privacy or seek their permission.
A staff member provided CQC inspectors with a tour of the home, and proceeded to take inspectors into a person's bedroom without seeking consent.
273/
A staff member provided CQC inspectors with a tour of the home, and proceeded to take inspectors into a person's bedroom without seeking consent.
273/
When an inspector prompted the staff member to seek the person's permission they looked surprised.
When the inspector asked the person's permission, they smiled and quickly got up and led inspectors into their bedroom.
[Imagine, being treated with respect]
274/
When the inspector asked the person's permission, they smiled and quickly got up and led inspectors into their bedroom.
[Imagine, being treated with respect]
274/
One person had mental health support needs. We observed the person suddenly become upset and begin sobbing.
The inspector looked to the staff member present who rolled their eyes and said, "He does this for attention."
[I actually have no words for this]
275/
The inspector looked to the staff member present who rolled their eyes and said, "He does this for attention."
[I actually have no words for this]
275/
The staff member offered no reassurance or support either during the period the person was upset, or after they appeared a little happier. There was no attempt made by the staff member to find out what may have caused the person's distress.
276/
276/
The person's records did not include a care plan for emotional wellbeing. A behaviour plan instructed staff, "not to react to the crying, offer [person] an activity of his choice."
277/
277/
Staff told us, and we observed, the strategy used was to redirect the person to their bedroom when they became upset.
On one occasion a staff member stood alongside the person trying to direct them to their bedroom.
278/
On one occasion a staff member stood alongside the person trying to direct them to their bedroom.
278/
The person said "push me" which prompted the staff member to say they hadn't pushed them.
Whilst we were satisfied abuse did not occur, the person's posture and refusal to move forwards, indicated they did not wish to be redirected.
279/
Whilst we were satisfied abuse did not occur, the person's posture and refusal to move forwards, indicated they did not wish to be redirected.
279/
This approach was not in line with behaviour plan. Another staff member then attended and helped person go outside in line with their choice.
Incident forms and behaviour charts for the same person for February and March 2022 showed 8 incidents where the person had cried.
280/
Incident forms and behaviour charts for the same person for February and March 2022 showed 8 incidents where the person had cried.
280/
There was no evidence of management oversight to review potential triggers.
Forms frequently stated the person cried without reason.
[Can you imagine this person's life. Imagine being so sad, crying at least once a week, and no-one bothering to understand or help]
281/
Forms frequently stated the person cried without reason.
[Can you imagine this person's life. Imagine being so sad, crying at least once a week, and no-one bothering to understand or help]
281/
One incident noted the person "Crying loudly and repeating 'I'm going', 'I'm going'" after staff member had incorrectly told them they wld see their family.
Form noted staff had told person they were going home without checking, which showed a lack of care for the person.
282/
Form noted staff had told person they were going home without checking, which showed a lack of care for the person.
282/
[The utter disregard for another human's feelings. This is so utterly, utterly brutal]
A lack of window covering on one person's bedroom meant their privacy and dignity was not adequately protected.
The window faced the front of building...
283/
A lack of window covering on one person's bedroom meant their privacy and dignity was not adequately protected.
The window faced the front of building...
283/
...and was partially missing a window covering throughout inspection.
Maintenance book confirmed the curtain pole had broken 6 March 2022.
Person was already known to experience poor sleep. We were concerned service failed to take timely action.
284/
Maintenance book confirmed the curtain pole had broken 6 March 2022.
Person was already known to experience poor sleep. We were concerned service failed to take timely action.
284/
CCTV cameras were mounted externally and in communal areas. The care consultant could not confirm the system had been switched off, explaining staff on-site could not access the system since the departure of the registered manager.
[What's point of so called consultant?]
285/
[What's point of so called consultant?]
285/
The nominated individual confirmed the CCTV wasn't in current use. There was no impact assessment on people's privacy or evidence about how people were consulted before the CCTV had been made operational.
Staff explained one person used another person's ensuite bath.
286/
Staff explained one person used another person's ensuite bath.
286/
We found boxes of the person's clothes were stored in the other person's bedroom, which a staff member stated was for ease of access.
This practice did not respect either person's privacy.
[All above ease for staff, all of it, never mind someone's life, home, bedroom]
287/
This practice did not respect either person's privacy.
[All above ease for staff, all of it, never mind someone's life, home, bedroom]
287/
Care plans and risk assessments contained no information about the safe management of bedroom door keys to promote privacy.
In relation to one person's bedroom, a staff member told us there had never been a key made available, meaning there was...
288/
In relation to one person's bedroom, a staff member told us there had never been a key made available, meaning there was...
288/
...no opportunity for person to lock their bedroom shd they wish for privacy or to protect their belongings.
We observed one person start to enter person's bedroom before being redirected by staff. There was a known risk of this person causing distress to the individual.
289/
We observed one person start to enter person's bedroom before being redirected by staff. There was a known risk of this person causing distress to the individual.
289/
Staff training in relation to equality and diversity, and person-centred care, was either incomplete or overdue refresher for all staff.
290/
290/
The service did not always ensure people were treated with dignity and respect.
This was a breach of Regulation 10 (Dignity and respect) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
291/
This was a breach of Regulation 10 (Dignity and respect) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
291/
We also observed positive interactions between some staff and people. We observed a staff member interacting with a person using the trampoline, throwing a large ball back and forth whilst they enjoyed bouncing.
[That sound, its the scraping of a barrel]
292/
[That sound, its the scraping of a barrel]
292/
During our inspection we observed people were inconsistently supported with their preferred methods of communication to enable their involvement and seek their views.
293/
293/
A relative commented,
'My feeling is that it's never been treated as a home for young people with a life ahead of them, but for older people.'
We found no evidence people had been supported to identify goals or develop independence skills.
[Non-lives]
294/
'My feeling is that it's never been treated as a home for young people with a life ahead of them, but for older people.'
We found no evidence people had been supported to identify goals or develop independence skills.
[Non-lives]
294/
Records and feedback confirmed relatives had not always been informed when accidents and incidents occurred, which meant they were not involved in decisions about how service responded to these.
295/
295/
A night care worker told us, and we observed, people were supported to get ready for bed by 9.30pm.
The night worker explained they carried out regular checks throughout the night, which included putting the light on to check people's faces to see if they were asleep.
296/
The night worker explained they carried out regular checks throughout the night, which included putting the light on to check people's faces to see if they were asleep.
296/
We asked if there was an offer of activities where ppl were awake during the night shift.
Staff member responded, "Night is not [for] activity, night is for sleep."
[Young people; tucked up in bed 9:30pm, lights blazing on ya while you sleep, but nothing if they wake ya]
297/
Staff member responded, "Night is not [for] activity, night is for sleep."
[Young people; tucked up in bed 9:30pm, lights blazing on ya while you sleep, but nothing if they wake ya]
297/
Care plans did not evidence that people had been supported to make choices about what time they went to bed or how they wished to spend their evening.
Care plans did not routinely specify whether people had a preference for staff gender.
298/
Care plans did not routinely specify whether people had a preference for staff gender.
298/
Staff advised one person was only supported by female staff, however this was not referenced in their care plan.
Another female person was supported by male staff for personal care, on occasions when only one female staff member was on duty.
299/
Another female person was supported by male staff for personal care, on occasions when only one female staff member was on duty.
299/
Staff told us person was comfortable with male support, however care plan did not provide guidance about staff gender and person was unable to express themselves verbally.
One person's care plan did refer to staff gender following previous concern about their behaviour.
300/
One person's care plan did refer to staff gender following previous concern about their behaviour.
300/
The service failed to consistently involve people and their representatives in decisions about their care.
This was a breach of Regulation 9 (Person-centred care) of the health and Social Care Act 2008 (Regulated Activities) regulations 2014.
301/
This was a breach of Regulation 9 (Person-centred care) of the health and Social Care Act 2008 (Regulated Activities) regulations 2014.
301/
[Responsive - inadequate]
At the last inspection this key question was rated as Good. At this inspection this key question has now deteriorated to Inadequate.
This meant services were not planned or delivered in ways that met people's needs.
302/
At the last inspection this key question was rated as Good. At this inspection this key question has now deteriorated to Inadequate.
This meant services were not planned or delivered in ways that met people's needs.
302/
Care plans were task focused and did not reflect a holistic picture of people's needs and preferences.
There was no evidence people were supported to learn new skills.
People were not supported to engage in a variety of external activities.
303/
There was no evidence people were supported to learn new skills.
People were not supported to engage in a variety of external activities.
303/
A staff member told us for two people other activities were "not possible" due to concerns people may touch members of the public or grab their food.
Another staff member expressed similar concerns.
304/
Another staff member expressed similar concerns.
304/
We were concerned staff confidence and skills in supporting people's behaviours had limited opportunities for external activities.
Limited on-site activities were observed in use, such as colouring, puzzles, watching TV, throwing a ball and use of a trampoline.
305/
Limited on-site activities were observed in use, such as colouring, puzzles, watching TV, throwing a ball and use of a trampoline.
305/
Whilst some people were observed to enjoy these activities, they did not offer opportunities to try new experiences.
For example, during several visits a person was repeatedly offered two tubs containing a mixture of puzzle pieces, crayons and blunt pencils.
306/
For example, during several visits a person was repeatedly offered two tubs containing a mixture of puzzle pieces, crayons and blunt pencils.
306/
Although the person enjoyed colouring, we did not consistently observe staff offering or encouraging a greater variety of indoor activities.
Some people had undated activity plans kept in the staff office. We did not observe staff referring to the activity plans.
307/
Some people had undated activity plans kept in the staff office. We did not observe staff referring to the activity plans.
307/
Staff member explained management of the service had recently created the documents.
[Well, well, well, what a surprise. No doubt these were drafted by the care consultant when they were buying the suite of policies to slap on file]
308/
[Well, well, well, what a surprise. No doubt these were drafted by the care consultant when they were buying the suite of policies to slap on file]
308/
It was unclear whether people had contributed to their activity plans and some of the suggested activities were vague, such as 'home activities' or contained insufficient activities for a meaningfully structured day.
[This. Is. Not. A. Life]
309/
[This. Is. Not. A. Life]
309/
For example, one person's activity plan contained one or two activities in the morning and afternoon such as hoovering, baking, arts and crafts, picnic, drive, walk, and 'home activities'.
The person was only able to engage in activities for brief periods.
310/
The person was only able to engage in activities for brief periods.
310/
With only one or two options on activity plan there was a lot of time where was nothing for person to meaningfully engage with.
We observed staff encouraging person to sit in lounge. The person did not appear to engage with the TV, which was showing children's programmes.
311/
We observed staff encouraging person to sit in lounge. The person did not appear to engage with the TV, which was showing children's programmes.
311/
[So much so wrong here. The lack of meaningful activity. The non-life. The fact that these are young people who are being encouraged to waste their days, lives, watching kids TV programmes.
TVs blaring. In homes where people are sensitive to noise.
Non-lives]
312/
TVs blaring. In homes where people are sensitive to noise.
Non-lives]
312/
Staff told us they needed more resources to promote meaningful activities.
A staff member commented, "[It] would be nice to have…more activities and opportunities for residents and resources…not loads here to try [with people]."
313/
A staff member commented, "[It] would be nice to have…more activities and opportunities for residents and resources…not loads here to try [with people]."
313/
One person did not have an activity plan at the start of our inspection. Their care plan noted they enjoyed shopping.
[People apparently always enjoy shopping. Do they really? Or is that all they know? The only chance they get to leave the house]
314/
[People apparently always enjoy shopping. Do they really? Or is that all they know? The only chance they get to leave the house]
314/
Financial records showed between 5 February 2022 and 26 April 2022 the person only had £3.35 personal spending money and there was no record of personal spending for this period.
315/
315/
Staff member expressed concern and told us person enjoyed shopping, and they wanted to help person shop for shoes, clothes and a handbag.
Provider explained the authority responsible for the person's finances had agreed an allowance of £50 per month in December 2021.
316/
Provider explained the authority responsible for the person's finances had agreed an allowance of £50 per month in December 2021.
316/
£100 was added to the person's spending account on 27 April 2021.
[This makes no sense. If they have £50 a month to spend, where the hell has it all gone? Financial fraud as well as everything else?]
317/
[This makes no sense. If they have £50 a month to spend, where the hell has it all gone? Financial fraud as well as everything else?]
317/
Staff did not consistently promote people's independence.
One person's speech and language therapy report stated, "[Person] can feed herself and should be encouraged to do so as much as possible prior to staff intervening."
318/
One person's speech and language therapy report stated, "[Person] can feed herself and should be encouraged to do so as much as possible prior to staff intervening."
318/
A staff member confirmed at times the person could feed themselves.
On one occasion we observed a staff member immediately start to feed the person by holding a spoon to their mouth, without any attempts to encourage independence.
319/
On one occasion we observed a staff member immediately start to feed the person by holding a spoon to their mouth, without any attempts to encourage independence.
319/
The service did not provide personalised care and support to meet people's holistic needs.
This was a breach of Regulation 9 (Person-centred care) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
320/
This was a breach of Regulation 9 (Person-centred care) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
320/
One person had developed a friendship with a person living at the adjoined care home.
On 27 April 2022 a staff member told us they had been advised the person was "not allowed" to go next door and would try to bring them back.
321/
On 27 April 2022 a staff member told us they had been advised the person was "not allowed" to go next door and would try to bring them back.
321/
Another staff member told us person "quite often quickly runs next door" adding "when weather nice have sat over with friend."
On last day of our inspection 5 May 2022 we observed person spent period of time visiting their friend and were supported to do so by staff member
322/
On last day of our inspection 5 May 2022 we observed person spent period of time visiting their friend and were supported to do so by staff member
322/
The nominated individual told us the service would explore further opportunities for planned joint external activities to further support the friendship.
[Can you imagine needing prompting to do this. I just can't. The adjoining care home is the one in special measures]
323/
[Can you imagine needing prompting to do this. I just can't. The adjoining care home is the one in special measures]
323/
The service was not fully compliant with the Accessible Information Standard.
Some care plans referred to the use of communication tools or techniques such as Makaton (a type of sign language) to help people understand information and communicate.
324/
Some care plans referred to the use of communication tools or techniques such as Makaton (a type of sign language) to help people understand information and communicate.
324/
We found staff use of these methods was inconsistent.
Training records confirmed staff had not received communication training.
325/
Training records confirmed staff had not received communication training.
325/
One person using service required spectacles. When viewing person's bedroom we located their spectacles in a drawer.
Staff member confirmed staff had not provided the spectacles that morning. They took the spectacles to the person to wear.
[Good on inspectors, horrific]
326/
Staff member confirmed staff had not provided the spectacles that morning. They took the spectacles to the person to wear.
[Good on inspectors, horrific]
326/
One person used Makaton and pictorial cards.
Our observations and staff feedback confirmed these communication methods were inconsistently used.
Two staff members supporting the person confirmed they did not know how to use Makaton signs.
327/
Our observations and staff feedback confirmed these communication methods were inconsistently used.
Two staff members supporting the person confirmed they did not know how to use Makaton signs.
327/
A staff member explained the person's pictorial cards had been lost.
We observed a staff member using some loose picture symbols; they explained the strip used with the cards to show 'now and next' had been lost.
[Utterly pointless without the structure]
328/
We observed a staff member using some loose picture symbols; they explained the strip used with the cards to show 'now and next' had been lost.
[Utterly pointless without the structure]
328/
Another person's care plan stated they used Makaton and visual aids such as pictorial symbols, now and next cards and picture menus. We did not observe visual aids used during our inspection, with the exception of one occasion when an agency staff briefly...
329/
329/
...showed the person a set of communication cards, although we observed the cards were used as a form of distraction rather than for the purpose of communication.
[Just typical. Whole lives are distracted, not lived]
330/
[Just typical. Whole lives are distracted, not lived]
330/
The same person was not consistently supported by Makaton trained staff.
An agency staff member providing care confirmed they could not use Makaton.
We observed limited interaction, focused on giving instructions.
331/
An agency staff member providing care confirmed they could not use Makaton.
We observed limited interaction, focused on giving instructions.
331/
On another occasion the person responded to Makaton, using a hand sign and smiling.
A staff member told us the person enjoyed using Makaton when the staff member we had observed was on shift, which indicated at other times their communication needs were not fully met.
332/
A staff member told us the person enjoyed using Makaton when the staff member we had observed was on shift, which indicated at other times their communication needs were not fully met.
332/
The service did not ensure people received personalised support to meet their communication needs.
This was a breach of Regulation 9 (Person-centred care) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
333/
This was a breach of Regulation 9 (Person-centred care) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
333/
We reviewed the service's compliments and complaints file. The policy accessible to staff within the file was effective October 2011, review date October 2014.
The service's complaints and compliments register was last updated in December 2016.
334/
The service's complaints and compliments register was last updated in December 2016.
334/
The service had logged a mixture of compliments and complaints during the period of 2015-2016.
It therefore appeared unlikely the service had not received a single compliment or complaint for the period 2017-2022.
335/
It therefore appeared unlikely the service had not received a single compliment or complaint for the period 2017-2022.
335/
A selection of Christmas cards inside the folder included a compliment from 2019.
Therefore we were not assured the complaints and compliments register had been appropriately maintained.
336/
Therefore we were not assured the complaints and compliments register had been appropriately maintained.
336/
Minutes of resident meetings showed these had been used to remind people about how to complain, however a resident meeting had not been documented since June 2021.
The monthly keyworker review template did not include a section about feedback from people...
337/
The monthly keyworker review template did not include a section about feedback from people...
337/
...meaning it was unclear how the service gathered and responded to feedback, concerns or complaints.
Systems were not operated effectively for identifying, receiving, recording, handling and responding to complaints.
338/
Systems were not operated effectively for identifying, receiving, recording, handling and responding to complaints.
338/
This was a breach of Regulation 16 (Receiving and acting on complaints) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
339/
339/
During our inspection the service was not supporting anyone receiving end of life care. Some people living at the service were younger adults.
340/
340/
One person's deprivation of liberty safeguards (DoLS) authorisation dated 4 April 2017 had noted the absence of an end of life care plan and included a recommendation from their advocate,
341/
341/
"IMCA [advocate]…has recommended for a 'When I die plan' to be put in place and for Penley Grange management to be encouraged to consider this."
We found no evidence this recommendation was acted upon.
342/
We found no evidence this recommendation was acted upon.
342/
A training course entitled "End of life planning" was identified on the service's training matrix, however the matrix confirmed staff had not completed this training.
[Matrix of non-training, non-interest, non-lives]
343/
[Matrix of non-training, non-interest, non-lives]
343/
We recommend the service ensures people are supported to make decisions about their preferences for end of life care and to ensure staff are aware of national best practice guidance and professional guidelines for end of life care.
344/
344/
The provider had purchased a suite of policies which were due to be implemented. These included an end of life care planning policy which referred to national best practice guidance.
[Purchased compliance, not sure this is gonna pan out too good]
345/
[Purchased compliance, not sure this is gonna pan out too good]
345/
[Well-led - inadequate]
At the last inspection this key question was rated as Good. At this inspection this key question has now deteriorated to Inadequate.
This meant there were widespread and significant shortfalls in service leadership.
346/
At the last inspection this key question was rated as Good. At this inspection this key question has now deteriorated to Inadequate.
This meant there were widespread and significant shortfalls in service leadership.
346/
Leaders and the culture they created did not assure the delivery of high-quality care.
A registered manager had been responsible for the service and an adjoined care home operated by the same provider.
347/
A registered manager had been responsible for the service and an adjoined care home operated by the same provider.
347/
A CQC inspection of the adjoined care home in February 2022 identified significant concerns.
The provider took the decision to suspend the registered manager due to concerns about their performance.
The registered manager also submitted their resignation.
348/
The provider took the decision to suspend the registered manager due to concerns about their performance.
The registered manager also submitted their resignation.
348/
This meant there was no registered manager at time of our inspection.
Prior to our inspection we received information of concern, alleging there was a poor culture and that the registered manager failed to provide recently recruited managers with access to documentation.
349/
Prior to our inspection we received information of concern, alleging there was a poor culture and that the registered manager failed to provide recently recruited managers with access to documentation.
349/
Director informed CQC they were aware the registered manager had been difficult to work with.
[So what did they do about that?]
Altho we were informed the director regularly met the registered manager, no supervisions, appraisals or development meetings were documented.
350/
[So what did they do about that?]
Altho we were informed the director regularly met the registered manager, no supervisions, appraisals or development meetings were documented.
350/
The service was supported by an on-site care consultant.
We could not be assured the consultant had upto-date knowledge to enable them to identify and effectively address concerns with staff practice.
[Certainly seems that way. Another industry of so called experts]
351/
We could not be assured the consultant had upto-date knowledge to enable them to identify and effectively address concerns with staff practice.
[Certainly seems that way. Another industry of so called experts]
351/
The consultant provided open feedback that although they had transferrable skills from their background as a specialist nurse, it had been "a lot of years" since they had worked with a learning disability service.
[How will this improve things for these people?]
352/
[How will this improve things for these people?]
352/
In relation to training for responding to people's behaviours they stated, "any training I've had [is] years out of date", but confirmed they had previously received training in techniques to respond to physically distressed behaviours, such as use of break-away techniques
353/
353/
One person experienced periods of agitation.
The consultant commented,
"I don't know how to deal with him…[I] would like to go on the training if it's available."
[Him.
In what world is this acceptable? Could I become a HGV consultant because I drive a car?]
354/
The consultant commented,
"I don't know how to deal with him…[I] would like to go on the training if it's available."
[Him.
In what world is this acceptable? Could I become a HGV consultant because I drive a car?]
354/
Consultant explained they planned to seek guidance from professional who had written person's positive behaviour support plan to help develop their knowledge of the person and how staff could effectively support their behaviours.
[So much industry propping up #socialcare]
355/
[So much industry propping up #socialcare]
355/
Sole acting team leader had not received training for their role, pending recruitment of team leaders.
In discussion with the care consultant on 19 April 2022 it became evident they were not aware who was on duty or plan for the day, such as staff ratios for a trip out
356/
In discussion with the care consultant on 19 April 2022 it became evident they were not aware who was on duty or plan for the day, such as staff ratios for a trip out
356/
There was a lack of oversight to ensure people's and staff safety.
The registered manager had not followed correct records management procedures; records were poorly maintained or inaccessible.
357/
The registered manager had not followed correct records management procedures; records were poorly maintained or inaccessible.
357/
We located confidential paperwork in an unlocked kitchen drawer.
The office was insecure because staff left the key in an unlocked key-safe.
Some records did not appear to have been reviewed or updated since 2017.
358/
The office was insecure because staff left the key in an unlocked key-safe.
Some records did not appear to have been reviewed or updated since 2017.
358/
We were concerned provider's monitoring had failed to address the deficiencies with records.
Supervision records were absent or poorly documented by registered manager.
Supervision record dated 1 Feb 2021 stated, "Deputy/good/privately. Missing money. Had phone money."
359/
Supervision records were absent or poorly documented by registered manager.
Supervision record dated 1 Feb 2021 stated, "Deputy/good/privately. Missing money. Had phone money."
359/
There was no explanation as to what this referred to.
Where staff had raised concerns during supervision, it was sometimes unclear what actions had been taken.
[Which is very generous framing. Could say no actions had been taken]
360/
Where staff had raised concerns during supervision, it was sometimes unclear what actions had been taken.
[Which is very generous framing. Could say no actions had been taken]
360/
A supervision record dated 17 August 2021 stated, "Atmosphere used to be enjoyable…atmosphere like school…nagging, not children." No explanation or actions were noted.
People's care records were not always accurate or contemporaneous.
361/
People's care records were not always accurate or contemporaneous.
361/
A night staff member told us when day staff were too busy, they would write handover records the following day.
They advised rather than documenting regular checks during the shift, they retrospectively documented all checks after 5am.
[Hear this in court all the time]
362/
They advised rather than documenting regular checks during the shift, they retrospectively documented all checks after 5am.
[Hear this in court all the time]
362/
We also identified numerous gaps in records for people's bowel movements, teeth brushing and bath and shower temperatures without explanation.
[And we wonder why so many learning disabled and autistic people die prematurely; such apathy, such disinterest, so little care]
363/
[And we wonder why so many learning disabled and autistic people die prematurely; such apathy, such disinterest, so little care]
363/
Care files frequently contained no references to reviews of risk assessments or behaviour support plans to evaluate whether these were appropriate or effective in preventing and reducing risks.
Governance systems did not effectively assess, monitor or improve the service.
364/
Governance systems did not effectively assess, monitor or improve the service.
364/
The service failed to securely maintain accurate, complete and detailed records in respect of each person using the service.
This was a breach of Regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
365/
This was a breach of Regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
365/
The provider had an action plan in place which was updated during our inspection with additional actions that had been identified to improve governance. A care consultancy was supporting the service to implement the action plan and recruit a new manager.
366/
366/
Following our initial visits to the service we were aware another consultant had also spent time on-site to support with the development of activity plans and care plans.
[Another one. #socialcare crisis apologists there's plenty of slush in the system. So much profit]
367/
[Another one. #socialcare crisis apologists there's plenty of slush in the system. So much profit]
367/
Systems were not established or robust enough to effectively assess, monitor and improve the safety and quality of the service.
Prior to the recent arrival of a care consultancy, there was limited evidence of oversight or auditing by the provider.
368/
Prior to the recent arrival of a care consultancy, there was limited evidence of oversight or auditing by the provider.
368/
We located an infection control and kitchen health and safety audit, dated January 2022, completed by an operations manager.
These audits had failed to identify and address concerns we found, such as gaps in staff training for infection control and food hygiene.
369/
These audits had failed to identify and address concerns we found, such as gaps in staff training for infection control and food hygiene.
369/
Where audits had taken place these were often undertaken at inconsistent intervals, had failed to identify known concerns or actions had not been taken to rectify the issues identified.
[Performative scrutiny. They're doing audits because they have to, they don't know why]
370/
[Performative scrutiny. They're doing audits because they have to, they don't know why]
370/
The kitchen and office first aid boxes contained a total of one plaster, which was not of a colour detectable for food handlers.
The monthly first aid box audit for Feb and March 2022 stated "Need to order" but records indicated the last items were ordered in January 2022.
371/
The monthly first aid box audit for Feb and March 2022 stated "Need to order" but records indicated the last items were ordered in January 2022.
371/
Governance systems were not operated effectively to reduce the risk of financial abuse.
We checked three people's personal money tins and found balances did not match the expected balances.
Audits had not been conducted monthly in line with the provider's policy.
372/
We checked three people's personal money tins and found balances did not match the expected balances.
Audits had not been conducted monthly in line with the provider's policy.
372/
Two people's records each contained two McDonalds receipts dated 11 November 2021.
The corresponding audits were 'ticked' to confirm no errors were found and there was no scrutiny of the receipts.
373/
The corresponding audits were 'ticked' to confirm no errors were found and there was no scrutiny of the receipts.
373/
In relation to one person the nominated individual confirmed staff had eaten the extra meal, stating previously staff had been advised they could purchase a small meal or drink for themselves weekly from the person...
[This is theft or fraud, take your pick]
374/
[This is theft or fraud, take your pick]
374/
...describing this as, "common practice…in this client group", adding "we have asked staff to refrain from this practice at this time whilst we review."
[Common practice in this client group. WTAF. Common practice. To infantalise people. Spend their money]
375/
[Common practice in this client group. WTAF. Common practice. To infantalise people. Spend their money]
375/
The director confirmed money for staff meals should instead have been taken from petty cash, rather than people's personal funds and it was stated a misunderstanding had occurred.
[A misunderstanding. It's theft. An abuse of power too]
376/
[A misunderstanding. It's theft. An abuse of power too]
376/
We submitted a safeguarding referral and the service confirmed they would audit records and started to reimburse people after our inspection.
We were advised payments had included an additional financial goodwill gesture to affected people.
377/
We were advised payments had included an additional financial goodwill gesture to affected people.
377/
[Where's the £50 a month that person had to spend. Regardless of whether we think less than £2 a day is enough for a grown adult to have to spend... wonder where all their money has gone]
378/
378/
The provider had not ensured policies and procedures were reviewed in response to learning from audits or changes to best practice guidance.
379/
379/
For example, the provider's 'Recruitment of personnel' policy, which was undated, referred to the CRB system for criminal records checks, which had been replaced with the Disclosure and Barring Service in December 2012.
380/
380/
Prior to our inspection an incident occurred where a night staff member was observed with their eyes closed.
We were advised the staff member had been spoken with.
[I think that's code for sleeping. On duty. Which I'm pretty sure wouldn't be allowed at your work]
381/
We were advised the staff member had been spoken with.
[I think that's code for sleeping. On duty. Which I'm pretty sure wouldn't be allowed at your work]
381/
On 28 March 2022 the nominated individual (NI) stated, "Additional spot checks are in place to mitigate the risks of recurrence."
[Oh yeh, spot checks to sneak up on sleeping staff, great plan. Very occasional I'll bet, and probably not documented, or even taking place]
382/
[Oh yeh, spot checks to sneak up on sleeping staff, great plan. Very occasional I'll bet, and probably not documented, or even taking place]
382/
We found limited evidence of spot checks.
Evidence from the NI confirmed a care consultant had been on-site overnight on 8 May 2022 to work on a care plan, but there were no details documented of how staff performance was monitored.
383/
Evidence from the NI confirmed a care consultant had been on-site overnight on 8 May 2022 to work on a care plan, but there were no details documented of how staff performance was monitored.
383/
We were also advised, "Although the provider completed some night spot checks, she did not formally record these. No manager night checks could be located."
Governance systems did not effectively assess, monitor or improve the service.
384/
Governance systems did not effectively assess, monitor or improve the service.
384/
The service did not consistently mitigate any risks relating the health, safety and welfare of people using services and others.
This was a breach of Regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
385/
This was a breach of Regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
385/
Service failed to comply with requirement to notify CQC of incidents that affected health, safety and welfare of people using the service.
Prior Apr22 service had last submitted a statutory notification in Dec19.
[Risk when CQC aren't in these places for years at a time]
386/
Prior Apr22 service had last submitted a statutory notification in Dec19.
[Risk when CQC aren't in these places for years at a time]
386/
Concerns that met criteria for allegations of abuse were not reported.
Following the departure of the registered manager, a care consultant had reported some new incidents to CQC, however, the service had failed to submit notifications for all recent safeguarding concerns
387/
Following the departure of the registered manager, a care consultant had reported some new incidents to CQC, however, the service had failed to submit notifications for all recent safeguarding concerns
387/
...and incidents they had been made aware of.
The service failed to notify CQC about incidents as required. This was a breach of Regulation 18 (Care Quality Commission Registration Regulations 2009).
388/
The service failed to notify CQC about incidents as required. This was a breach of Regulation 18 (Care Quality Commission Registration Regulations 2009).
388/
Engagement with families had been inconsistent. Prior to one recent meeting with relatives, we found no evidence surveys or meetings were facilitated to gather views about the running of the service.
389/
389/
Family comments in relation to communication inc, "The previous manager wasn't good at responding to emails. Communication on her part wasn't great" and "I'd go to the manager, although I don't know who the manager is, and that is one of my issues…it's the communication"
390/
390/
People were not meaningfully engaged and involved in the running of the service.
Prior to the recent arrival of a care consultancy, there was limited evidence the provider had taken steps to address longstanding risks the service presented of a closed culture.
391/
Prior to the recent arrival of a care consultancy, there was limited evidence the provider had taken steps to address longstanding risks the service presented of a closed culture.
391/
There were multiple potential warning indicators, inc failures to identify safeguarding concerns, lack of suitable induction, training and supervision of staff, high use of agency staff, care plans not reflecting person's voice and communication plans not being followed.
392/
392/
Whilst we noted the provider had recently appointed an operations manager, we could not identify their input as having brought about meaningful change before they were suspended on 23 March 2022.
They resigned and left the service.
[State of this place]
393/
They resigned and left the service.
[State of this place]
393/
Staff meeting minutes dated 27 July 2021 described a poor culture.
Minutes included, "Discussed [regarding] the staff attitudes, behaviours on the floor in front of residents. Residents have been copying what the staff are saying on the floor"
394/
Minutes included, "Discussed [regarding] the staff attitudes, behaviours on the floor in front of residents. Residents have been copying what the staff are saying on the floor"
394/
"All staff problems, fights, arguments must be left outside the building…Staff must maintain resident's privacy and dignity. If there is a resident having personal care or using bathroom, another resident must not be taken to same bathroom for change or use the toilet"
395/
395/
[I mean honestly. What sort of toxic cesspit is this place?
This is people's home.
Imagine this drama and abuse is going on in your home, and you can't leave, and you can't spend your own money, and you can't communicate because no-one bothered to learn your language]
396/
This is people's home.
Imagine this drama and abuse is going on in your home, and you can't leave, and you can't spend your own money, and you can't communicate because no-one bothered to learn your language]
396/
There were no actions added to indicate how the manager intended to monitor staff culture.
We received mixed feedback from staff. The consistent message from staff was a desire for management continuity and access to more resources to enhance activities for people.
397/
We received mixed feedback from staff. The consistent message from staff was a desire for management continuity and access to more resources to enhance activities for people.
397/
One staff member provided positive feedback regarding the former registered manager, stating they had worked with her for a number of years and had no concerns.
Another staff member stated when the registered manager hadn't been onsite they were easily contactable.
398/
Another staff member stated when the registered manager hadn't been onsite they were easily contactable.
398/
However, some staff told us the registered manager had failed to act to fully address their concerns, such as ongoing concerns regarding one person's behaviour.
Although regular staff meetings were held, a staff member advised staff had become frustrated.
399/
Although regular staff meetings were held, a staff member advised staff had become frustrated.
399/
They explained at first the registered manager "actually was listening", however described this had changed. In relation to staff meetings they commented, "Most [of the] time meetings [were] always the same, same things, no solutions"
Not all staff were treated fairly.
400/
Not all staff were treated fairly.
400/
We were advised by the nominated individual that "cultural" attitudes amongst some staff meant there was an expectation females would complete domestic tasks.
Two staff raised concerns regarding two managers who had recently resigned and left the service.
401/
Two staff raised concerns regarding two managers who had recently resigned and left the service.
401/
A staff member alleged when performance issues had been raised by the managers, this had been done in a manner which caused them distress.
Records and feedback indicated health and social care professionals had sometimes been involved in people's care.
402/
Records and feedback indicated health and social care professionals had sometimes been involved in people's care.
402/
For example, recent social care reviews had been carried out and some people had regular reviews with a psychiatrist.
However, the service did not consistently implement professional guidance to achieve good outcomes for people.
[Pointless performative involvement then]
403/
However, the service did not consistently implement professional guidance to achieve good outcomes for people.
[Pointless performative involvement then]
403/
Systems were not consistently operated to seek and act on feedback from people using the service, those acting on their behalf, staff and other stakeholders to continually evaluate the service and drive improvement.
404/
404/
This was a breach of Regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
405/
405/
Accidents and incidents had not been adequately monitored to identify potential notifiable safety incidents.
At the time of our inspection we did not identify any recent notifiable safety incidents based on incident records we reviewed.
406/
At the time of our inspection we did not identify any recent notifiable safety incidents based on incident records we reviewed.
406/
We identified indicators of a closed culture at the service. There was no evidence the previous registered manager had provided information, and where relevant an apology, to people or their representatives when accidents or incidents had occurred.
407/
407/
Relatives comments included, "We wouldn't know if there were any [incidents]" and "I have been informed in the past, but it's probably been awhile, about 18 months ago they said she had a fall or something."
408/
408/
We recommend the service reviews their approach to ensure duty of candour responsibilities are met.
[Penley Grange have to write report of action they'll take. No doubt non-care consultant will do that. I hope CQC are shutting this place down before they have the chance]
409/
[Penley Grange have to write report of action they'll take. No doubt non-care consultant will do that. I hope CQC are shutting this place down before they have the chance]
409/
[I was hoping to cover all inadequate reports today but had no idea that one was that long, or that bad.
So apologies, I'll return to others another time. Too much grim for one day.
Thanks to everyone who reads and comments, and my crowdfunders chuffed.org/project/openju…]
/END
So apologies, I'll return to others another time. Too much grim for one day.
Thanks to everyone who reads and comments, and my crowdfunders chuffed.org/project/openju…]
/END
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