Archived: New Redvers

Updated 16 September 2021

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.

Inspection team

The inspection team consisted of three adult social care (ASC) inspectors, a medicines inspector and an Expert by Experience who had consent to phone and gain feedback on the care provided by the service from people’s relatives. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

New Redvers is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service did not have a manager registered with the Care Quality Commission. At the time of the inspection the service was being managed by the providers Chief Executive Officer (CEO) and a consultant who had been engaged by the provider to make improvements.

A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered provider, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Notice of inspection

The first day of the inspection was unannounced.

What we did before the inspection

Before the inspection we reviewed the information we held about the service, including notifications we had received. Notifications are changes, events or incidents the provider is legally required to tell us about within required timescales. We sought feedback from the local authority. We used this information to plan the inspection. The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report.

During the inspection-

We spent time with and spoke with 10 people living at the service, six relatives, four members of staff, a consultant who had been engaged to support the service, the CEO, the Nominated individual and a director of Diamond Care (2000) Limited. The nominated individual is responsible for supervising the management of the service on behalf of the provider. To help us assess and understand how people's care needs were being met we reviewed six people's care records. We also reviewed a number of records relating to the running of the service. These included staff recruitment and training records, medicine records and records associated with the provider's quality assurance systems.

We used the Quality of Life Tool and the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at training data and quality assurance records. We spoke with six health care professionals, and representative from Torbay Council's quality assurance and improvement team (QAIT) and one relative. We made five safeguarding referrals and advised a health care professional to raise another.

Updated 16 September 2021

New Redvers is a residential care home that provides personal care and support for up to 19 people with a learning disability, autism or who have complex needs associated with their mental health. At the time of the inspection there were 11 people living at the service.

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 guidance CQC follows to make assessments and judgements about services supporting people with a learning disability or autistic people

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

The provider could not show how they met some of the principles of Right support, right care, right culture. This meant we could not be assured that people who used the service were able to live as full a life as possible and achieve the best possible outcomes.

People told us they were happy, and they liked living at New Redvers. One person said, “I like living here.” Another said, “We have had a lot of staff changes here, I miss some of the old staff, but I like the new staff too. They are very nice.” Another person said “Since (name of CEO) and (name of consultant) have been here it become 1000% better. They have been spending money decorating. We have some chickens; food is much better and hopefully we are getting some pigmy goats.”

Although people told us they felt safe and were happy living at New Redvers, the service did not focus on people's quality of life, and care delivery was not person centred. Staff knew people well, but they did not recognise how to promote people's rights, choice or independence.

The culture of the service did not reflect best practice guidance for supporting people with a learning disability or autistic people. Senior managers and staff did not understand the underpinning principles of Right support, right care, right culture guidance, or how these could be used to develop the service in a way which supported and enabled people to live an ordinary life, enhanced their expectations, increased their opportunities and valued their contributions.

People’s human rights were not upheld, staff used punitive practices as a way of controlling people’s behaviour and language used by staff was disrespectful and demeaning. People were not involved in a meaningful way in the development of their care and support and information was not provided in a way which met people’s individual communication needs. All of which created a closed culture, which increased people’s dependence on staff who had limited understanding of how to support people in a way which upheld their human rights.

People’s basic right to privacy and dignity and to be free from all forms of discrimination under the Equality Act 2010, was not always understood by staff or respected. This meant that people experienced a poor quality of life which was not person centred as staff did not put the needs of people first.

People were not always protected from the risk of abuse or avoidable harm. We found where some risks had been identified, sufficient action had not always been taken to mitigate those risks and keep people safe. Key pieces of information relating to people's care and support needs were not always being recorded or followed up. Other risks were well managed.

People were not supported to have maximum choice and control of their lives and staff were not supporting people in the least restrictive way possible and in their best interests.

People who had behaviours that could challenge themselves or others, had proactive plans in place to reduce the need for restrictive practices, however, these were not always followed. Support did not always focus on people’s quality of life and staff did not regularly evaluate the quality of support given, involving the person, their families and other professionals as appropriate.

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

People were not supported by staff who understood best practice in relation to learning disability and/or autism. Governance systems did not ensure people were kept safe and received a high quality of care and support in line with their personal needs.

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

Rating at last inspection and update

The last rating for this service was inadequate (published 12 February 2021). Following that inspection, the provider was asked to complete an action plan to show what they would do and by when the improvements would be made. This was not received by the Commission.

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

Why we inspected

This was a planned inspection based on the previous rating and to provide assurance that the service is applying the principles of Right support, right care, right culture.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We have found evidence that the provider needs to make significant improvements. Please see the safe, effective, caring, responsive and well-led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for New Redvers on our website at www.cqc.org.uk.

Enforcement

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 discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in regulation in relation to safe care and treatment, safeguarding people from abuse, the need for consent, staffing, recruitment, notifications, duty of candour and governance. Please see the action we have told the provider to take at the end of this report.

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

The overall rating for this service is ‘Inadequate’ and the service therefore remains 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, 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.

We will meet with the provider following this report being published and work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.