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We are carrying out a review of quality at Heron House. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary


Overall summary & rating

Inadequate

Updated 24 March 2021

About the service

Heron House is a residential care home providing care to three people who needed support with their mental health or living with a learning disability at the time of our inspection. The service can support up to six people in two buildings.

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

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 and systems in the service did not support this practice.

People were at risk of harm from themselves and each other. When incidents occurred, there was a lack of oversight from the provider, which led to further incidents. The provider had not learnt from incidents. Staff did not have the training or the expertise to support people with their complex needs. There was a lack of guidance for staff to follow on how to support people to de-escalate situations. People were subject to abuse and had been physically harmed. The provider had failed to take action to review people’s welfare and inform the relevant stakeholders.

Risks to people’s health needs were poorly managed. Referrals to healthcare professionals had not been made when required. People told us they were unhappy living at the service. Staff who lacked knowledge about Mental Capacity had placed unnecessary restrictions on people and this had not been identified by the provider. The provider oversight was poor and ineffective. The provider failed to address concerns raised at our last inspection on 4 August 2020. At this inspection we found the service had further deteriorated. People had not been involved in making decisions about the service. When suggestions had been made by people, these had not been implemented by staff and management. There was a negative culture at the service, which was not person centred.

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 providing support to people with a learning disability and/or autistic people.

The service was not able to demonstrate how they were meeting the underpinning principles of Right support, Right care, Right culture. People had unnecessary restrictions placed on them, which triggered incidents of behaviour that could be challenging. Some parts of the service were restricted, for example the kitchen, a communal bathroom and the office. Staff did not have the competencies and skills to support people in a person-centred way, which had a negative impact on people. The provider had not taken action to address these shortfalls.

Right support:

• Model of care and setting did not maximise people’s choice, control and Independence

Right care:

• Care was not person-centred and did not promote people’s dignity, privacy and human Rights

Right culture:

• Ethos, values, attitudes and behaviours of leaders and care staff did not ensure people using services lead confident, inclusive and empowered lives

Following this inspection, we worked closely with the local authority (Kent County Council) to ensure people were safeguarded from ongoing harm. One person was supported to move out of Heron House, and alternative placements are being sought for all service users.

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 Requires Improvement (published 24 September 2020). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been made and the provider was still in breach of regulations.

Why we inspected

The inspection was

Inspection areas

Safe

Inadequate

Updated 24 March 2021

The service was not safe.

Details are in our safe findings below.

Effective

Good

Updated 24 March 2021

Caring

Good

Updated 24 March 2021

Responsive

Good

Updated 24 March 2021

Well-led

Inadequate

Updated 24 March 2021

The service was not well-led.

Details are in our well-Led findings below.