Background to this inspection
Updated
27 October 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.
As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.
Inspection team
The inspection was carried out by two inspectors.
Service and service type
Heron House 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. This means that the provider is legally responsible for how the service is run and for the quality and safety of the care provided.
Notice of inspection
This inspection was unannounced.
What we did before the inspection
We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. 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. We used all of this information to plan our inspection.
During the inspection-
We spoke with two people who used the service about their experience of the care provided. We spoke with five members of staff including a manager from another of the providers services, a consultant manager, a team leader, a support worker and an agency support worker. We reviewed a range of records. This included two people’s care records and multiple medication records. We looked at three staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.
After the inspection
We continued to seek clarification from the provider to validate evidence found. We looked at training data and quality assurance records.
Updated
27 October 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 prompted in part due to concerns received about incidents between people, allegations of abuse and staff competencies. A decision was made for us to inspect and examine those risks.
We reviewed the information we held about the service. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.
The overall rating for the service has changed from Requires Improvement to Inadequate. This is based on the findings at this inspection.
We have found evidence that the provider needs to make improvement. Please see the safe 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 Heron House on our website at www.cqc.org.uk.
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 coronavirus and other infection outbreaks effectively.
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 continued breaches in relation to safe care and treatment, staffing, good governance, and new breaches in relation to safeguarding and notifications of other incidents at this inspection.
Following the inspection, we took immediate action to restrict admissions to Heron House. We took action against the provider and cancelled their registration for Heron House. Everyone who received a regulated activity has moved out of the service, and we have de-registered Heron House with the Care Quality Commission.