Archived: Clubworthy House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement.

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

The service was in breach of legal regulations in relation to safeguarding and staffing.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about the culture of the service. Lessons were not learnt to continually identify and embed good practice, and they failed to identify where working practice caused distress to people.

Staff told us they felt unable to raise concerns and the provider failed to recognise elements of poor practice which impacted on people’s physical and emotional safety. Staff told us the provider lacked insight into the culture of the service and did not support staff to raise concerns or disagree with them. One staff member said, “I got paid to agree”. Another staff member told us the provider did not welcome input from other health professionals. They said, “They [the provider] hated people coming to the house; I’ve lost count of the complaints they made against other health professionals”.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The provider worked well with other health professionals and services to support people’s physical health and wellbeing. They supported people to access health services at appropriate times and ensured people’s individual needs were met so they could access treatment. For example, playing music whilst attending an appointment to ensure one person was comfortable and relaxed.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not recognise or share concerns quickly or appropriately.

Despite having appropriate policies, the provider failed to report or investigate allegations of physical and verbal abuse. There were no systems to ensure allegations made against the provider or the registered manager were independently investigated or reviewed. One person told us they had seen [provider] “scream in [person’s] face”. A staff member told us “[provider] shouts back at [person] if they shout or throw stuff, they say it’s desensitising, or mirroring”. Another staff member told us, “[Provider] laid on the floor next to [person] and screamed at [them] like they were a child”. We heard from multiple staff that the provider would routinely swear at people in an aggressive manner.

The provider failed to recognise that a closed culture existed at the service. Staff told us the provider had regularly behaved in ways which were described as controlling and coercive. One staff member said, “It’s a closed culture, there’s no one to hold them to account”. Another staff member told us, “There were subtle methods of control and punishment, like if they [people] weren’t well enough to feed the animals, they weren’t well enough to have a hot chocolate. Or if they didn’t want to do the cleaning, their afternoon activity wouldn’t be safe to do because of their behaviour”. Staff raised concerns about the boundaries between personal and professional relationships and told us people living at the service were treated more like family members or members of staff. This meant they were at times treated with love and affection, but at other times were picked up on jobs not done correctly, or behaviour which the provider deemed inappropriate.

The provision of care failed to maximise people’s choice, control, and independence. Decisions were routinely made for people, and weekly routines were planned in advance. Weekly plans included household tasks such as shopping, cooking, cleaning and looking after the many animals at the property. People and staff did those tasks together as a group, and people living at the service had little choice about how to spend their time on a daily basis. One person told us they did what was on the schedule, because otherwise the provider would “get grumpy” with them. A staff member said, “Weeks are meticulously planned, it’s like a military camp, if anyone suggests anything different, they will find an excuse and say it’s unsafe because of the service user’s behaviour”. Another staff member told us “They [people] end up agreeing to do what the provider wants, they have to have their own way”. A third staff member said, “We’re not allowed to take people out in the car or anything, everything is done as a group, everything is planned in advance”.

People were not supported to make decisions about their life, care and treatment in line with the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. Where appropriate, authorisations to deprive people of their liberty had been applied for, however, mental capacity assessments had not been completed which in one person’s case meant the provider was not satisfying the legal conditions of the authorisation.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risk assessments were completed and people were supported to keep themselves safe. People took part in a range of activities and tasks which involved elements of risk and did so safely.

However, when people communicated their needs, emotions or distress they were not consistently supported in a way that protected their rights and dignity. People’s care plans did not contain information to support staff to recognise and effectively manage foreseeable risk or situations which may cause people distress, nor guide staff on how to respond in the least restrictive way. Staff told us they witnessed poor responses to people’s emotional behaviours, which escalated risks rather than minimised them. This included restricting people’s movement by blocking doorways, raising voices and making threats as a ‘consequence’, which would further distress the person.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The environment was well maintained and safe for people to live and work in. Equipment was maintained and there were effective practical fire safety procedures. We signposted the provider to guidance to ensure their fire risk assessment was regularly reviewed and updated in line with best practice.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

As a small service, the providers were an integral part of the team providing support and care. At the time of our inspection, they were recruiting and were covering any unfilled shifts themselves to ensure continuity of care, in addition to their usual working hours. Rotas showed the providers also covered all sleeping shifts and were the only staff members on duty overnight for the whole month. This meant they were scheduled to work in excess of 80 hours a week each. Staff told us the providers were “almost always” present at the service, even on their scheduled days off. One staff member said, “They will say they never get a day off in front of the service users, it makes them feel like a burden.” The registered manager told us they had only had “3 days off together in 17 years”.

Staff were recruited safely and received regular supervision; however, they told us they felt undermined and de-skilled by the provider’s approach. One staff member said, “They are lovely people, but they have a control issue and will deskill you, because it all has to be done their way, right down to the way we chop the carrots”. Another staff member said of a supervision they received, “I have never been ripped apart so brutally in my life, I was in tears. You come away absolutely broken, with your confidence on the floor”.

Staff completed appropriate training but were not empowered to implement it and it was not embedded into practice.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service was clean and appropriate handwashing facilities were available. People were supported to wash their hands after tending to the animals or working outside. Staff had completed appropriate training including infection control and food hygiene, and people were included in this as appropriate.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People received their medicines safely and systems were in place to monitor and audit medication systems. Staff had completed appropriate training, and people were supported to understand their medicines and why they took them.