The Care Quality Commission (CQC) has rated Autism Hampshire 102a and 102b Brockhurst Road inadequate overall following inspections of these services in November and December. Both services, which were previously rated good overall, have now been placed in special measures.
102a, and neighbouring 102b, are residential care homes providing accommodation and personal care to people with a learning disability and autistic people. Both services can support up to four people and, at the time of the inspection, six people were being cared for across the two services.
CQC carried out an unannounced focused inspection of 102a to look at how safe, effective and well-led the service was after concerns were received about the leadership and the safety of people using the service. At the time of the inspection, the service had a newly appointed manager. Following the inspection, the overall rating dropped from good to inadequate, and the ratings for safe, effective and well-led also dropped from good to inadequate.
The inspection at 102b was also focused and unannounced. Inspectors looked at how safe and well-led the service was after concerns were received about safeguarding incidents and a lack of leadership. Following the inspection, the overall rating dropped from good to inadequate, and the ratings for safe and well-led also dropped from good to inadequate.
Debbie Ivanova, CQC deputy chief inspector for people with a learning disability and autistic people, said:
“We expect health and social care providers to guarantee people with a learning disability and autistic people the safety, choices, dignity, and independence that most people take for granted. When we inspected 102a and 102b Brockhurst Road, we found the people who called these services home, were being failed by leaders.
“We found unacceptable practices that created anxiety for the people in the service. We observed incidents which were not managed well and where people were at risk of harm. There was also a blame culture preventing staff from speaking out when things weren’t right as they didn’t feel comfortable doing so. We informed the local authority safeguarding team who took action to reduce the immediate risk of harm to people.
“One home was not clean or well-maintained, the kitchen was dirty and some food was out of date. More worryingly, people weren’t being treated with respect and dignity. We saw some people had stained sheets and mattresses, and one person’s bathroom had mould growing on the floor and on their personal belongings. People should be able to expect a much more dignified way of living.
“All of these things we found are indicative of a closed culture.
“Leaders at both Brockhurst Road homes need to do better. It’s clear staff want to provide better care for people living there, but need much more support from management to do so. Staff need to be supported to have the right skills, knowledge, training and understanding of people’s needs to provide this. Leaders also need to address the low staff numbers to ensure people can lead happy fulfilling lives and help them take part in activities they enjoy and gain more independence.
“We have told the provider to make a number of improvements in both homes and have received action plans outlining how they intend to do this. We are also now considering what further action we may need to take to keep people safe. In the meantime, we will monitor the service closely to ensure that improvements are made and fully embedded.”
Inspectors found the following at both services:
- Indicators of a closed culture were identified, and people did not receive a service that provided them with safe, effective, compassionate and high-quality care
- The provider did not have enough oversight of the service to ensure that it was being managed safely and quality was maintained. Quality assurance processes had not identified all of the concerns in the services and where they had, sufficient improvement had not taken place
- The provider had not ensured there were sufficient numbers of competent and skilled staff to support people safely
- The provider had not established an effective system to ensure people were protected from the risk of abuse
- Risks to people's health and wellbeing had not been monitored or mitigated effectively. People were at risk of harm because staff did not always have the information they needed to support people safely
- Records were not always complete
- People were not always given the opportunity to feedback about care or the wider service.
At 102a Brockhurst Road inspectors found the following:
- Leadership was poor and the service was not well-led. Governance systems were ineffective and did not identify the risks to the health, safety and well-being of people or actions for continuous improvements
- The service was not maximising people's choices, control or independence. There was a lack of person-centred care and people's human rights were not always upheld
- A lack of timely action by leaders to ensure the service was well staffed and safeguarding incidents were responded to, meant people did not lead inclusive or empowered lives
- There were areas in the home which could pose a risk of harm to the people living there. Some areas were so poorly maintained they could not be cleaned properly. In one person’s bedroom there was a large metal sheet fixed to a wall with glue which had become partially unstuck, and in a person’s bathroom there was a sheet of plaster board fixed to a wall with large metal screws that could easily be removed
- People were not always provided with a varied and nutritious diet based on their individual preferences to promote their health and wellbeing
- The principles of the Mental Capacity Act 2005 were not understood and applied. 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.
At 102b Brockhurst Road inspectors found the following:
- Staff did not have the skills or knowledge to support people in a positive way in order to reduce their anxiety levels. Staff told us they worked excessively long hours and morale was low which meant people did not always receive high-quality care. Agency staff were used to cover staff shortages, but there was no evidence of Staff induction records for them. The use of agency staff also meant that people were not always supported by staff who knew them well and understood how to meet their needs to keep them safe
- Inspectors were told there was a blame culture in the service which made staff feel uncomfortable about raising concerns
- The home was not clean or well-maintained, presenting health and safety concerns. The kitchen was dirty, some food was out of date, one person’s bedroom had food on the floor and rubbish down the side of their bed, another person’s bedsheets and mattress were stained and one person’s bathroom had mould growing on the floor and on their personal belongings
- The home was not secure. One person needed to be accompanied when leaving the home for their safety. A coded keypad was in place to stop them from leaving unaccompanied, however, the person knew the code and was seen leaving the home. The side gate was also not secured. Cupboards containing chemicals were not always locked, putting people at risk of harm
- Fire management was not safe as fire doors were damaged, there was a lack of testing firefighting equipment and not all staff had received fire safety training
- Some people’s care plans contained conflicting information
- Staff told inspectors they recognised and reported safeguarding incidents, but management told CQC they were not always aware of all concerns and therefore did not always report them to CQC and the local safeguarding team. This meant that action was not always taken to keep people safe
- Medicines were not managed safely, and medicine administration records were not always complete.
Read the report pubished on the CQC website:
Autism Hampshire - 102a Brockhurst Road
Autism Hampshire - 102b Brockhurst Road
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