About the service: The Fieldings is a care home that provides personal care for up to 47 people, over two floors in one adapted building. It is registered to provide a service to people who have mental health needs. At the time of the inspection 35 people lived at the home.People’s experience of using this service: The service was not safe. People were exposed to the risk of abuse and violence. People were placed at serious risk of harm as risks associated with their care and support and the environment were not managed safely. Opportunities to learn from incidents had been missed which meant people had been exposed to the risk of avoidable harm. The home was in a very unhygienic state and people were not protected from the risk of infection. Staff were not deployed effectively to ensure people’s safety. Safe recruitment practices were followed.
People were supported by staff who did not have the required skills or competency to provide safe and effective support. People’s physical and mental health needs were not always met. Care and support was not properly planned and coordinated when people moved between services. Care was not always delivered in line with current legislation and standards. People were not supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible; the policies and systems in the service did not support this practice. The environment was not well maintained and this posed a risk to people’s safety.
People were not treated with dignity and their right to privacy was not upheld. People told us that staff were kind and caring. However, care plans lacked information about people which meant staff did not always have enough information to provide person centred care. There was an inconsistent approach to involving people in decisions about their care and support.
People did not consistently receive personalised care that met their needs. People were not consistently provided with opportunity for meaningful activity. No value or acknowledgement was given to complaints made by people living at the home, as opposed to complaints made by members of the public and relatives.
The provider did not have effective oversight of the home and the manager did not have sufficient time or support. Consequently, there had been a failure to identify and address serious issues with the safety and quality of the service. Systems to monitor and improve the quality of the service were not effective. Where audits had identified areas for improvement, action had not been taken to address issues. The provider had not implemented learning from serious incidents. Failings in leadership and governance placed people at risk of harm.
The service met the characteristics of Inadequate in all areas; more information is in the full report.
Rating at last inspection: Good (report published 14 July 2017).
Why we inspected: We brought this inspection brought forward due to information of concern and a serious incident which occurred at the home.
Enforcement: You can see what action we told the provider to take at the back of the full version of the 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: We will continue to monitor intelligence we receive about the service until we complete our next planned inspection. If any concerning information is received we may inspect sooner.
The overall rating for this service is ‘Inadequate’ and the service therefore remains in ‘special measures’. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.
If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.
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.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk