The Care Quality Commission (CQC) has taken action against a Birmingham service for people living with a learning disability and autistic people - following an inspection which led to it being rated inadequate.
CQC inspected Summerfield House, ran by N H Care Limited, in August. The residential care home provides personal care for up to five people. At the time of inspection, four people were living at the home.
Due to the serious level of concerns found, CQC took urgent action to keep people safe by placing conditions on the service’s registration, including restricting any new admissions to the home and requesting a report of the actions taken and to be taken as a result of the urgent condition.
At the same time, the local authority organised an external agency to provide managerial support in the home. Inspectors returned to find there had been four further allegations of physical abuse and there was no evidence these had been investigated to consider if staff had responded appropriately or lessons could be learnt to prevent further occurrences.
People living in the home have all been supported to move out to alternative accommodation to ensure their safety and wellbeing.
Summerfield House was rated inadequate overall and for being safe, effective, responsive, caring and well-led.
Debbie Ivanova, CQC deputy chief inspector for people with a learning disability and autistic people, said:
“Our latest inspection of Summerfield House found a truly unacceptable service with a poor culture where abuse and people being placed at harm had become normal, with no action taken to prevent incidents from happening or reoccurring.
“Records showed incidents of physical, verbal and emotional abuse incidents which had not been dealt with appropriately or followed up. Physical assault between people had become commonplace, made worse by a widespread lack of recognition from staff about the inappropriate and abusive practices going on.
“Care records and the language used by staff to speak to people were derogatory with no thought given to people’s dignity and wellbeing.
“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 and this was not happening.
“Services must inform CQC and other statutory bodies when they identify safeguarding concerns such as these to ensure people’s safety. This service’s continued failure to refer all instances of abuse and thoroughly investigate concerns has put people at prolonged risk of harm and created a closed culture at the home.
“We continue to monitor the service closely and will take further action if we are not assured the necessary and urgent improvements are made.”
The vulnerable people at Summerfield House should have been supported to lead confident, inclusive and empowered lives but instead were subject to poor care, harm and abuse. Staff didn’t support people, meet their needs or ask what their personal needs and desires were.
People's care was based on ill-informed information rather than a full assessment of their needs. Care plans stated they had not been involved in reviews due to their learning disability.
Inspectors found several serious concerns on inspection, including:
- People were not protected from abuse. Records showed incidents of physical, verbal and emotional abuse which had not been responded to
- Records showed staff making threats to cancel people's activities, call the police when people were anxious and on one occasion use furniture to prevent a person from moving. The staff response and approach to these incidents demonstrated a significant lack of understanding about people's needs and the safe management of anxiety
- Staff did not always recognise abuse. For example, inspectors saw a person being hit on the head by another person. This was not recognised as a safeguarding incident and no immediate action was taken to safeguard either person or consider how to prevent this happening again
- There was no record that any staff discussions had taken place to consider the management of incidents and to discuss inappropriate and abusive staff practices
- Good infection prevention control practice in relation to COVID-19 were not always followed. Some staff did not wear masks and there was no policy in place for visitors to keep the spread of infection to a minimum
- Where it was identified that people were at risk of choking, there were insufficient risk assessments in place to prevent this from happening.
Full details of the inspection are given in the report published on our website.
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