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Archived: Mendip House Inadequate


Inspection carried out on 12 May 2016

During a routine inspection

Mendip House is a large detached bungalow situated in the extensive grounds of Somerset Court. The home accommodates six people who have autism and complex support needs. Five people live in the main part of the home; one person lives in a self-contained annexe. People living at Mendip House can access all other facilities on the Somerset Court site which include various day services.

A registered manager was responsible for the service, although they were not currently working at the home. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, 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.

We received serious concerns in relation to this service in May 2016. As a result we inspected urgently on 12 May 2016. This was unannounced and carried out by two inspectors. Following this inspection visit we liaised with the provider, the police and the local authority safeguarding team. We then carried out further unannounced inspection visits on 14, 15 and 17 June 2016. These were also carried out by two inspectors.

People had not been kept safe. A damaging culture had been allowed to develop within the staff team which had adversely affected people’s lives. Staff had not ensured people’s safety; this had been compromised for some time. Risks to people were not properly assessed, reviewed or managed. Staff had not reported concerns about people’s welfare and safety when they had them.

Some areas of medicines management were not safe. Staff recruitment was not managed safely. Accidents and incidents were not always recorded or followed up to ensure people’s safety or improve their care. Health and safety checks on the home were not carried out which put people at risk.

Current staff were kind and caring but people had not been treated with kindness and compassion previously. People appeared relaxed in the company of current staff on duty. Staff knew the people they were supporting. Staffing was adequate to ensure the continuity of people’s service. Experienced staff from some of the provider’s other services on the Somerset Court site were working in the home to provide cover for the staff who were not currently working. There were permanent staff on each shift.

People’s health care support was poor as health care records were either missing or poorly recorded. People’s health plans did not reflect their current needs. People’s legal rights in relation to decision making and restrictions on their liberty were not upheld.

People did not have a choice of nutritious meals and drinks. Some people’s diets were very poor placing them at risk of malnutrition.

Staff training was not put into practice; some training was out of date. Staff were not supervised regularly and concerns raised in supervisions were not acted upon. Poor staff practice was not addressed and improved.

Some people did not have any formal system to communicate their wishes or feelings. People were therefore unable, and had not been supported to express their views about life in the home. Staff had not raised concerns or complaints on people’s behalf despite the culture prevalent within the home adversely affecting them. Concerns and complaints had not been listened to or responded to. Staff reported a failure to act on concerns they raised which led to them not reporting them any longer.

People did not receive personalised care which was responsive to their needs. Care planning was confusing and out of date. Plans were not reviewed and did not reflect people’s current needs. Some records could not be located during the inspection; there was evidence these records had never been completed.

The home had been extremely poorly managed. There had been a chaotic approach to management systems, structures and record keeping. The provide

Inspection carried out on 11 February 2014

During a routine inspection

Because of people's complex needs and varied communication abilities we were not able to speak with people who used the service. However we spoke with two parents and three staff individually.

There were appropriate arrangements in place to assess people's capacity to make specific decisions such as a need for medical treatment. People were empowered to make choices about their daily living arrangements and in achieving goals and aspirations. Where people were assessed as not being able to make informed decisions best interests meetings had been held. Decisions had been made on their behalf in consultation and discussion with other professionals and people's representatives. However there were inconsistencies about how best interests decisions were made and these arrangments had not always been followed. People had access to independent advocates to help them in making decisions and ensuring decisions had been made in people's best interests.

Comprehensive assessments had been completed to ensure people received a consistent and reliable service. Assessments were in place to address potential risks to people's health and welfare and provide support to staff in responding and alleviating identified risks.

There were improved arrangements in place following a concern related to the management of people's financial affairs. The provider had acted professionally and appropriately in responding to the concerns about the management of people's financial affairs. Action had been taken in ensuring people's financial affairs were protected.

There were appropriate and safe arrangements for the administering and management of people's medicines. We saw there were individualised plans in place for the effective administering of medicines.

There were effective systems in place to monitor and review the quality of the service. The provider was proactive in learning from incidents and seeking support from professionals to alleviate risks to people.

Inspection carried out on 27 February 2013

During a routine inspection

People who lived in the home had communication difficulties so we were not able to ask some people about life in the home. People who lived in the home who we were able to speak with told us they were well cared for and that staff asked them about life in the home and listened to their views.

We asked one person if they were happy living at the home; they said �yes I am�. People who were unable to express their views verbally appeared relaxed and content. We spoke with one parent. They told us they were �always kept up to date� by staff at the home.

The staff we observed supporting people clearly knew them well and understood their needs. Staff told us they thought people were happy living at the home; one staff member said �People are well cared for here.� None of the staff we spoke with had any concerns about any person being at risk of abuse. Staff understood the various signs of abuse and knew what action they needed to take to ensure people were safe.

Staff had not received all of their training or were overdue when refresher training was needed. Supervision meetings had not been provided regularly. Newer staff had not had their probation reviews carried out so their performance had not been formally assessed.

An annual quality review was completed in 2012. All of the people who lived at the home were all satisfied with the care and support they received.

The systems in place to monitor and assess the quality of the service were not fully effective.

Reports under our old system of regulation (including those from before CQC was created)