Archived: Vision Rolleston

About the service

Vision Rolleston is a small residential care home. It is registered to support up to four people. At the time of the inspection, two people were using the service. The service mostly supports people with mental health, learning disabilities and physical health.

The service is registered to be at the address 20 Rolleston Street, Leicester, LE5 3SA. However, when we arrived at the inspection, we were informed the service had moved to 1 Greenlawn walk, Leicester, LE4 0BN. This location is not part of the provider’s condition of registration. We are therefore considering our next enforcement action for this different location. Our inspection occurred at this 1 Greenlawn walk address, to ensure people were being supported safely.

People’s experience of using this service and what we found

People were not protected from the transmission of COVID-19. The service was unclean and government guidance related to COVID-19 was not followed. Environmental risks like fire and legionella were not managed safely. People’s care plans did not provide clear guidance to help staff keep people safe. Staff did not receive high quality training, to ensure they had the skills to support people. Medicine administration was not always recorded in a timely way, but were otherwise given safely.

Safe recruitment processes were not in place, to ensure staff were of good character and suitable skilled to work at the service. There was often only one staff member at the service, this was not always enough staff to meet both people’s needs.

Incidents that occurred at the service were not always well managed. The provider’s oversight of these incidents was poor quality, this effected the ability to learn lessons when things went wrong.

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; the policies at the service guided good practice, but were not followed effectively.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people. The provider was not registered to support people with learning disability needs, but we found that both people at the service had these needs. The service was not able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture:

Right support: The model of care did not maximise people’s choice, control and independence. People were not involved with creating their care plan and were not happy with the type of care provided to them. The care did not always maximise people’s independence.

Right care: Care was not person centred. Staff did not always ensure people received suitable and timely support from external health and social care professionals. Restrictive practices were used and these did not promote people’s dignity and human rights. Incident records showed staff were not always skilled to support people’s care needs.

Right culture: The service did not have a good ethos. People described that decisions were made “at the last minute” and they were not always involved with changes made to the service.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

This service was registered with us on 4 March 2019 and this is the first inspection.

Why we inspected

We received concerns about the safety of infection control processes during the COVID-19 pandemic. The inspection was therefore targeted to look specifically at infection control processes. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively. This included checking the provider was meeting COVID-19 vaccination requirements

When we inspected, we found concerns with the restrictions imposed on people’s freedom. We therefore widened the scope of the inspection to become a focused inspection. This included the key questions of safe, effective and well-led.

We have found evidence that the provider needs to make improvements. You can see what action we have asked the provider to take at the end of this full report.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to regulation 12 (Safe care and treatment), regulation 19 (fit and proper persons deployed), Regulation 11 (Consent) and regulation 17 (Good Governance)

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Special Measures:

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.