Thread by @GeorgeJulian

These windows aren't shutting themselves, onto archived services.

2 services I reported on in July have already closed

https://twitter.com/GeorgeJulian/status/1545281795096301568

and

https://twitter.com/GeorgeJulian/status/1555139764961120256

Now @AffinityTrust Specialist Support Division North https://t.co/uHgyRPwXzD has shut down

1/

The original report into the Specialist Support Division North had no enforcement action recorded on its publication date, 22 June

Now the report is re-issued with enforcement action taken and the service is archived.

2/

Which does suggest @CareQualityComm are taking action, behind the scenes, once reports are published.

I guess larger providers are choosing to close services, rather than improve them.

There are more services that have been recently archived coming up.

3/

Next one is @Hftonline Home Farm Trust is a large learning disability charity, and this relates to Rowde who @CareQualityComm finally decided had had enough chances to improve and...

"We served a Notice of Decision to remove the location from the providers registration".

4/

Let's dig into this a bit further, after all there's a LOT of talk at the moment about the #socialcarecrisis and claims that Covid and Brexit were behind the collapse of #socialcare.

Large learning disability charity, let's look into the decline of one of their services....

5/

2014

Rowde residential service provides accommodation for up to 36 people with a learning disability.

People who use the service reside in bungalows on a central site.

@CareQualityComm inspected on 29 May 2014, report published June 2014, @Hftonline met all standards

6/

February 2016 unannounced inspection, report published March16

"During our inspection we looked at six people's care and support plans and identified people's records were not always accurate and did not always reflect their current needs"

CQC asked @Hftonline take action

7/

A year later @CareQualityComm return to see whether things have improved

"A breach of legal requirements was found.. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breach of Regulation 9"

8/

April 2017

"We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements"

All was tickety boo

Does it stay that way? You can guess

9/

Inspection Feb 2018, report published 2mths later

Unannounced inspection by two inspectors and an expert by experience.

Things are awry. The registered manager has left, there are two breaches, of Regulation 12 Safe care and treatment and Regulation 11 Need for consent

10/

"The care service has not been fully developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance.

These values include choice, promotion of independence and inclusion".

11/

"The service supported 37 people. Whilst these were across five individual bungalows and adjoining self-contained flats this model of care would not be registered if an application were to be received at this moment in time"

12/

Medicines weren't managed safely; there were inadequate risk assessments; out of date health and safety checks.

"Relatives and staff consistently raised their concerns with us about the staffing shortages they had experienced"

2018 - staffing problems long before covid

13/

"Relatives and staff raised concerns regarding the communication they received from the office and senior management staff"

Management failings

Gaps in recording and record keeping.

CQC again ask @Hftonline to take action to improve things; especially the two breaches

14/

Just three months later, July 2018, @CareQualityComm are back (notice that this report wasn't published until 5mths later).

This is the first time that @Hftonline Rowde is rated inadequate; the inspection was over 4yrs ago.

So why were CQC back so soon?

15/

"The inspection was prompted in part by notification of an incident following which alleged sexual abuse claims have been made concerning people who use the service".

Great big campus establishment, there's a reason that they wouldn't be registered now

16/

"Some of these incidents are historical and occurred prior to HF Trust Limited taking over and others have continued during this providers governance.

The notification was reported by the service to The Care Quality Commission and the Adults safeguarding team".

17/

"This incident is currently being investigated by the Adults safeguarding team. The Care Quality Commission are reviewing the information and considering what regulatory action to take".

18/

"At this inspection we found the service remained Requires Improvement in the effective domain but was now rated as Inadequate in safe and well-led.

We did not inspect caring or responsive at this time".

19/

"We identified three new breaches of the Regulations, Regulation 13 Safeguarding service users from abuse and improper treatment, Regulation 17 Good governance and Registration Regulation 18 Notification of other incidents".

20/

"The service remains in breach of the two Regulations from our inspection in February 2018, Regulation 11 Consent and Regulation 12 Safe care and treatment".

Dec 2018 Rowde is inadequate and placed into special measures

21/

"Following this inspection, we wrote a letter of intent to the provider to seek reassurance on how they would mitigate the immediate concerns and risks to people.

The response received did not initially alleviate concerns and we requested further information be sent".

22/

"The provider has now provided an action plan on how they will address these concerns.

We have served a Notice of Decision against this location to impose urgent conditions".

@Hftonline weren't allowed to admit anyone without CQC's prior agreement

23/

"Further to this, the provider must submit a monthly report detailing how they ensure the service people receive is safe.

This includes information on risks, incidents and quality monitoring".

The detail of what they found is pretty grim

24/

CQC found that @Hftonline were in breach of 5 regulations.

They took enforcement action, imposing conditions on the provider's licence, and issuing a Notice of Decision to vary the conditions longer term.

That inspection was 4yrs ago. What's happened since then?

25/

Skip forward to the next report, March 2019 to see what happened....

"At the last comprehensive inspection in July 2018, the service was rated Inadequate overall and was placed into 'Special measures' by CQC.

Enforcement action was taken..."

26/

"A Notice of Decision was served against this location to impose urgent conditions.

A further Notice of Decision was served to cancel the provider's registration for this location.

The provider submitted representations to tribunal".

27/

It's worth noting there are legal firms who advertise as specialists in defending providers, and arguing against these notices.

Who will help with drafting responses and appeals to the tribunal.

I'm not sure whether they stop and consider the people in these places

28/

March 2019

"This inspection took place to check if the provider had made sufficient improvements, in order for the Care Quality Commission to withdraw the Notice of Decision".

29/

"Altho there are still areas of improvement, enough progress had been made to withdraw our Notice of Decision.

The provider will continue to provide monthly reports to The Care Quality Commission for ongoing monitoring and new admissions will not be admitted at this time".

30/

March 19 they're out of special measures, but what did inspectors find and what more do we learn about Rowde?

"The service did not have a registered manager at the time this inspection took place".

This shd be reason enough to shut it down if you ask me, given the history

31/

We know it wouldn't be registered if it applied now, even in 2018

"The majority of people living at Rowde were from out of county Local Authorities.

This meant that some people were living long distances from their relatives".

[Why did the tribunal not close it down?]

32/

"A lot of people living at Rowde had moved to this site when another large residential home in Devon run by the previous provider had closed".

I live in Devon, have just checked Google Maps, would be a 5hr round trip to visit.

Right to family life anyone?

33/

I can't find any transcript from the First Tier Tribunal so we don't know what was discussed, but I struggle to understand how they could have decided to keep this place open.

Especially with what more we hear CQC found...

34/

"We saw that agency staffing was used in every bungalow which impacted the consistency and experience of care for people.

For example, staff spoke about how people's behaviour could change when they knew agency staff would be on shift".

35/

"During our inspection we witnessed an incident by which an agency member of staff did not turn up for their shift. The management of this was not effective".

If you need agency staff routinely, care will be unsafe, and people won't know their carers. Shut it down already

36/

"We found there was improved recording on what had happened and the action taken in seeking medical advice.

However, there was not always detail documented on preventative measures that were considered to reduce the risk from happening again..."

37/

"...or if there were any lessons learnt from each incident."

How any tribunal can accept that, when a place was inadequate due to safeguarding concerns, is beyond my comprehension.

Do the people who live there not matter?

38/

"Overall, we found the service to have made progress in starting to embed change and making improvements to the concerns identified.

The staff morale was an area that still needed work".

39/

"Staff were open and honest about how they felt and this would only improve as the service continued to make the necessary changes and became stable and settled."

Imagine living in an environment where you need care and support, and those providing it are miserable.

40/

How could a tribunal find that the place didn't need shut down, when it wasn't good for safety or leadership?

How? Let's dig into the impact of agency staff

"The level of agency staff being used across site to maintain staffing levels continued to be high".

41/

"For example, in December 2018 and January 2019 one bungalow totalled an agency amount of 1707 hours.

Another bungalow had a total of 811 agency hours.

We saw that agency staffing was used in every bungalow which impacted the consistency and experience of care for people"

42/

"Staff commented

"There is too much agency everywhere. They don't know ppl as well as we do. We have asked one agency staff not to return.

People get agitated and worried if it's agency, we can see their behaviour change when they know""

Tolerated impact on people's QOL

43/

"Another staff said "we do have to have agency and some are good but people want regular staff. People we support don't have the normal relationship with agency that we have with them.""

How can a tribunal know that and decide is safe to be open, agency staff routinely used

44/

March 2019 report also identified people not being able to go to activities off-site due to lack of regular staff, and

"drivers not always being available to take people to their chosen activities. This concern had been previously raised for people living across this site"

45/

Staff said they'd raised these issues with management, who claimed to have no knowledge.

"Staff told us they had raised this internally but senior management confirmed they were previously unaware of this incident"

Do the Tribunal read reports of what life is like for ppl?

46/

"During our inspection we witnessed an incident by which an agency member of staff did not turn up for their shift.

One member of staff stayed over their shift waiting and repeated calls were made to management during this time".

47/

"We observed the unsettled impact this had on people with some people continually getting up to check out of the windows and discussing the concern with staff.

One staff commented "We have a lot of agency staff most days. A lot of staff have left.""

48/

"An hour later we returned to see if the agency staff had arrived but they had not.

Staff told us they now had a member of staff from another bungalow.

We went to the other bungalow to see if they were staffed appropriately and found they were not".

49/

"There was meant to be three staff but there was two and would only be one staff member between 6pm and 9pm.

A new staff member was present, but they were on their first shift and only shadowing".

50/

"The other staff member had not worked many shifts in this bungalow due to the new rota changes.

We spoke with the temporary manager who was overseeing this bungalow who told us it had been sorted"

Imagine, telling a CQC inspector its all sorted, when it clearly aint.

51/

"We informed them that we had checked this and found it not to be the case.

The manager asked us if we wanted them to go over to the bungalow.

It had to be explained it was not our responsibility to make this decision for them but it was not safe to be left this way".

52/

"We did not have confidence this was managed appropriately and further raised our concerns the next day with senior management who said it would be investigated".

How do a Tribunal square that reality for people, who live their, and staff, with being safe to remain open?

53/

I can't even face copying and pasting all this out.

How is this a way for people to live? Breaches. Tolerated by a Tribunal.

If a Tribunal is happy to accept care in breach of regulations, then it's really no wonder providers aren't motivated to improve.

54/

March 2019 and the Tribunal has allowed it to stay open, and there's a breach of regulation relating to staffing - which apparently @Hftonline will address

This is 3.5yrs ago

So what happened next?

[Anyone else exhausted with rage? Imagine living there]

55/

Fast forward another year, and things are even worse.

March 2020, just as we go into lockdown, and it still requires improvement.

"The service did not always (consistently) apply the principles and values of Registering the Right Support and other best practice guidance".

56/

"This service had five bungalows all located on one site in a 'campus' style.

This model of care would not be registered if an application were to be received now".

But would still be tolerated by a Tribunal when CQC tried to close it down; as ppl endured life there

57/

"The provider had not taken steps to ensure this service fitted into the residential area.

There were identifying signs that this was a care home.

For example, there was a large sign advertising the provider visible from the pavement and road".

Two in fact

58/

"Quality monitoring was not robust and did not give an accurate oversight of the service.

We found healthcare records for three people were conflicting and did not always have the guidance staff needed".

Tolerated by Tribunal. Non-care. Non-lives.

59/

"Two people had additional monitoring needs for their health, we found they were not always being carried out.

People were not living in an environment that was thoroughly cleaned".

60/

"Accidents and incidents had been recorded but we found one incident where staff had not followed the provider policy in seeking medical help"

61/

"People were supported by sufficient numbers of staff. There was still reliance on agency staff, but hours needed had reduced. The service tried to use the same agency staff for consistency"

62/

"Rating at last inspection (and update) - The last rating for this service was requires improvement (published 20 March 2019).

The provider completed an action plan after the last inspection to show what they would do and by when to improve."

63/

"We have identified one breach in relation to governance.

This is the 4th consecutive requires improvement or Inadequate rating for this service.

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety"

64/

Surely there should be a three strikes and you're out rule, these are people's lives at stake.

Fourth consecutive report that needed improvement.

So this will be the fourth consecutive action plan with promises of improvement I guess.

No urgency. It's only people's lives.

65/

A year later, July 2021, @CareQualityComm were back at Rowde and they were placed in special measures again due to being inadequate.

This report was published in September 2021, but has been updated since hence the date of July 2022.

66/

"This inspection was unannounced. The second day of the inspection was started at 19:00hrs".

Gotta hand it to @CareQualityComm am *loving* seeing these out of house unannounced inspections.

What did they find...

67/

"Care was not always person-centred and did not promote people's dignity at all times.

People were not living in a service with the right person-centred culture. An incident had taken place whereby staff placed people at risk of harm".

68/

"The provider had taken immediate action to deal with the incident but the ongoing mitigation of risk of reoccurrence was inadequate.

This placed people at risk of harm".

Oh I dunno, its like it could have been predicted when CQC tried to shut them down the first time

69/

"People did not have their medicines as prescribed.

There had been multiple medicines incidents and/or errors since the last inspection.

Whilst people were not harmed the inadequate systems and governance around medicines management placed people at risk of harm".

70/

[I honestly don't know how we can ever be certain that people weren't harmed when CQC write this.

Maybe no blatant obvious incident occurred, but what for people living there.

When all these breaches are found, it's often said ppl were not harmed. I'm not so sure]

71/

"Risk management was not safe.

Since the last inspection we had been notified or made aware of six episodes of actual or near miss choking incidents."

This is care from a large learning disability charity @Hftonline @ChtyCommission

Death making

72/

"People were at risk of harm as safety measures put in place were not appropriate or personalised.

People's care plans and health action plans held conflicting info for staff which could cause confusion.

People might not receive care and support they needed at all times"

73/

"Quality monitoring was not effective.

This was the fifth consecutive rating of requires improvement or inadequate for this service.

The provider had not been able to make sure their systems and processes identified improvement required".

This is cultural

74/

How much time/effort/expense has a large learning disability charity spent arguing against CQC's judgement? Just improve

Like @mencap_charity actions to ensure night staff don't receive full pay.

These are not actions that will improve the lives of learning disabled people

75/

"Action had not been carried out to improve on the last inspection's findings, therefore the service remained in breach of Regulation. We also found a further two breaches of Regulation at this inspection".

Breach after breach after breach. Breaking the law.

76/

"The last rating for this service was requires improvement (published 25 April 2020). The provider completed an action plan after the last inspection to show what they would do and by when to improve".

These so called action plans are non-action performative scrutiny

77/

"At this inspection enough improvement had not been made and the provider was still in breach of regulations.

This service has deteriorated to inadequate.

This service has been rated requires improvement or inadequate for the last five consecutive inspections".

78/

"The inspection was prompted to seek assurances about the safety and care of people following information received as part of ongoing safeguarding concerns and a police investigation".

While a Tribunal allowed this place to stay open. Zero concern for people there.

79/

"As investigations were ongoing this inspection did not examine the circumstances of those incidents. We wanted to seek assurance about the wider safety measures for people at the service".

80/

"We undertook a focused inspection to review the key questions of safe, effective and well-led only.

We have identified breaches in relation to person-centred care, safe care and treatment and good governance"

81/

July 2021 - Action that @Hftonline were apparently going to take and the enforcement action that @CareQualityComm took.

One more report, when they went back six months later coming up...

82/