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

Inspection Summary


Overall summary & rating

Inadequate

Updated 4 December 2019

About the service

Tarry Hill is a care home in the New Mills area of Derbyshire. The home is made up of five separate houses in one communal setting. The home is registered to care for up to 26 younger adults and people with learning disabilities and autistic spectrum disorder and older people. At the time of the inspection there were 18 people living there.

The service had been developed and designed before the principles and values that underpin Registering the Right Support had been published. This guidance aims to ensure that people who use the service can live as full a life as possible and achieve the best possible outcomes. The principles reflect the need for people with learning disabilities and/or autism to live meaningful lives that include control, choice, and independence. The service was larger than current best practice guidance.

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

The service was not safe. People were subject to excessive control and restraint. Staff and managers had not recognised and taken action in relation to safeguarding incidents and potentially abusive practices. The use of physical intervention and restraint was not assessed or planned for and staff did not have appropriate training to enable them to perform physical intervention safely. Staff had been harmed as a result of poor behaviour management. Opportunities to learn from adverse incidents had been missed.

Environmental risks were not managed safely and the environment was not clean and hygienic. Medicines were not always safely managed resulting in some people getting too much or too little medicine. There were not always enough staff to ensure people’s safety in the event of an incident. Safe recruitment practices were followed.

People’s rights under the Mental Capacity Act were not upheld. People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not always support this practice. Staff had not received the training they needed to complete their role safely and effectively. People’s support was not always provided in accordance with national standards or good practice. The environment was adapted to meet people’s needs.

People were not always treated in a dignified way. Feedback about the approach of staff was mixed. There was a lack of consistency in the quality of support people received. Several staff expressed concern about some people’s wellbeing and told us they were unable to provide appropriate support to some people. The approach to promoting people’s independence was inconsistent. People and their relatives had been involved in developing parts of their support plans.

People did not consistently receive personalised care that met their needs. People were not always provided with opportunity for meaningful activity. There were systems to manage complaints but some relatives told us they had to chase up a response to their complaints or concerns.

Tarry Hill was not well led. The provider did not have effective oversight of the home. 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 provider was not always open and transparent and did not always meet the duty of candour.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was Requires Improvement (published November 2018). The provider completed an action plan after the last inspection to show what they wo

Inspection areas

Safe

Inadequate

Updated 4 December 2019

The service was not Safe.

Details can be found in our Safe findings below.

Effective

Inadequate

Updated 4 December 2019

The service was not Effective.

Details can be found in our Effective findings below.

Caring

Requires improvement

Updated 4 December 2019

The service was not always caring.

Details can be found in our Caring findings below.

Responsive

Requires improvement

Updated 4 December 2019

The service was not always responsive.

Details can be found in our Responsive findings below.

Well-led

Inadequate

Updated 4 December 2019

The service was not always well-led.

Details can be found in our Well-led findings below.