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Inspection report

Date of Inspection: 8 August 2011
Date of Publication: 12 October 2011
Inspection Report published 12 October 2011 PDF

People should be protected from abuse and staff should respect their human rights (outcome 7)

Not met this standard

We checked that people who use this service

  • Are protected from abuse, or the risk of abuse, and their human rights are respected and upheld.

How this check was done

Our judgement

People living in the home were not sufficiently protected from abuse or the risk of abuse. Staff were not always following prescribed behaviour plans and one to one support requirements were not consistently being met. Until recently, reporting of safeguarding incidents to the local authority safeguarding team and the Care Quality Commission had been inconsistent.

Overall we found that improvements were needed for this essential standard.

User experience

One of the people living in the home told us he had not seen staff using physical restraint “because they are not allowed to”. He described the new behaviour management system which had recently been introduced, which was called Crisis Aggression Limitation and Management (CALM) and said he thought it would be a good thing when people can be restrained, but only as a last resort. He said he feels safe with the staff and people he lives with but this was because he could “look after himself” and people “wouldn’t dare pick on him”. He said he had never seen any excessive force used and had not yet seen staff using CALM.

Other evidence

We saw various individual risk assessments in the files we examined. Some of these were accompanied by behaviour plans and detailed guidelines to identify how staff should act to address the specified behaviour, or minimise the risk of harm to the individual or others. These documents had been reviewed recently. Some of the information on file was incomplete. For example, in one case there was a statement that the person was on a supervision order but there was no paperwork to support this.

In some cases staff were failing to safeguard the people in the home by not following the specified behaviour plans. Some people living in the home were not being supported 1:1 by staff in accordance with their risk assessments or behaviour plans. On one file there were records of aggressive behaviour towards staff which detailed over 300 instances in July. The guidelines were clear about how staff should speak when interacting with him but, as noted in outcome 4, these were not being followed. At one point a person began to behave in an aggressive fashion and no de-escalation techniques were seen to be used by staff to try to diffuse the situation.

One agency staff was not able to be specific in describing individual behaviour plans. She said she was always on duty with a permanent staff member who dealt with any behavioural issues. She said she had not seen anyone being restrained. When asked about how she would respond to a safeguarding issue, one new staff member was unclear and unable to describe the reporting process. She told us she had received a detailed induction before starting in the home. She said she had received instructions on residents, other staff, the building, risk assessments and challenging behaviour. Another staff member told us that the behaviour of people living in the home had deteriorated and behavioural guidelines were not followed because there were not enough staff to do so. She said that the behaviour plans themselves were very clear and hoped that staff would be more confident in using CALM. However, she added that some staff were still afraid to use the CALM physical restraint techniques.

Until recently staff in the home had been trained in techniques called Strategies for Crisis Intervention and Prevention (SCiP) for behaviour management. Staff told us that they had been told not to use the physical restraint techniques by the previous manager. In addition, one staff member said that this manager had not responded to staff concerns about the resulting escalation in peoples’ behaviour and people in the home had not always been safeguarded as they should have been.

The local safeguarding team had raised concerns about inconsistent recording and reporting of incidents between people in the home, to the safeguarding team and the Care Quality Commission, with the provider. Concerns about the level of aggressive incidents between people in the home triggered this inspection by the Commission. An action plan was produced by the team brought in by the provider to address these concerns. All of the staff were due to have been trained in the new behaviour management system by the end of the week of our visit. The system includes quarterly reporting of the use and effectiveness of the specified techniques to the system’s developers. In addition to this, experienced senior staff had been drafted into the home to develop staff awareness of the importance of consistency and of following behaviour plans. The staffing levels had also been increased to help enable this. The safeguarding team had asked that the home write to families informing them of issues and concerns that had arisen in the home and how they were being addressed. This had not been done at the time of our visit.