The Care Quality Commission (CQC) has told New Redvers, a care home in Torquay, to make urgent improvements to keep people safe following an inspection in June.
New Redvers cares for up to 19 people with a learning disability, complex mental health needs, or autistic people. At the time of the inspection there were 11 people living at the service and it did not have a manager who was registered with CQC. Instead, it was being managed by the provider’s chief executive officer (CEO) and a care consultant who had been employed by the provider to make improvements.
The overall rating for the service following the previous inspection was inadequate, and it was placed in special measures*. The inspection in June was carried out to review the service and check that it was applying the principles of right support, right care, right culture.
Following the latest inspection, the rating for the service remains inadequate. It is also rated inadequate for being safe, effective and well-led, and requires improvement for being caring and responsive. The service therefore remains in special measures and it is being supported by the local authority to keep people safe.
Debbie Ivanova, CQC’s deputy chief inspector for people with a learning disability and autistic people said:
“When we inspected New Redvers we found a service that wasn’t providing a safe or caring home for people living there. Staff had limited understanding of how to support people in a way which upholds their dignity, choices and human rights. This is completely unacceptable. We have told the provider to make urgent improvements to the service and we will take further enforcement action to ensure that people are safe.
“It was unacceptable that we found staff speaking to people in a way which was disrespectful and demeaning. Additionally, staff did not recognise how to support people who were experiencing periods of emotional distress. On occasions, staff were also using punishments as a way of controlling people's behaviour. One person was told they would not be able to go for a meal due to their behaviour, and another was told they could not go out in their wheelchair as they had put on too much weight.
“We saw that people were not always protected from risks associated with their complex care needs. One person who needed bedrails to keep them safe, had fallen from their bed and fractured a bone which wasn’t discovered for six days as staff didn’t seek medical advice. It was the second time this person had fallen with no action taken to prevent it from happening after the first fall. We also found records indicating that some people who were at risk of choking had been given inappropriate foods, and some people had choked, which required intervention from staff.
“Additionally, there were restrictions on people’s liberty as people were prevented from leaving the home without being accompanied. Some people had restraints used on them, in the form of lap belts or bed rails, with no legal basis to do so. Institutionalised practices, such as introducing a bar and tuck shop at the home, were being used. These were described by the CEO and consultant as evidence of outstanding care, when they should have been supporting people who were able to leave the service safely, to do so.
“All of this adds up to an environment which is best described as a closed culture. People are entitled to a life of their choosing which gives them the opportunity to fulfil their ambitions. This was not happening at New Redvers and the situation cannot continue. However, the provider has told us they are committed to improving the service for the people living there. We will keep a close eye on this service and if we are not satisfied that sufficient improvements have been made, we will not hesitate to use our legal powers to ensure that they are.”
Inspectors found the following issues at the service:
- Leaders did not have the skills, knowledge and experience to perform their roles. Following the previous CQC inspection, the provider had engaged the services of a consultancy to assume day to day management of the service. However, they did not carry out any due diligence or background checks of the consultancy or its employees
- People were not supported by staff who understood best practice in relation to people with a learning disability and/or autistic people. Governance systems did not ensure people were kept safe and received a high quality of care and support in line with their personal needs
- Managers did not investigate or use the learning from incidents and accidents to keep people safe. Staff recorded 11 safeguarding incidents between February and June 2021. All these incidents had been reviewed by the CEO or the consultant, however, they had not recognised them as abuse and failed to report them to the local authority for further investigation and follow up. Nor did they see this as an opportunity to understand and support people to manage their emotional distress and reduce the risk of reoccurrence
- People were not always protected from the risk of abuse or avoidable harm. Inspectors found that where some risks had been identified, the provider had not always taken action to mitigate the risks and keep people safe
- People were placed at the risk of harm as staffing arrangements at night and during the day were not sufficient to meet people's needs safely. Night-time staffing cover consisted of one waking and one sleeping staff member in a separate flat at the top of the building. This is despite the fact that one person needed to be repositioned every two hours to minimise the risk of pressure sores. Another person required staff to check on them hourly throughout the night and required the use of emergency medicine for the management of their epilepsy. Another person required the use of oxygen therapy during the night and required staff to check on them hourly
- Key pieces of information relating to people's care and support needs were not always being recorded or followed up. Other risks were well managed
- People were not supported to have maximum choice and control of their lives and staff were not supporting people in the least restrictive way possible and in their best interests
- People who had behaviours that could challenge themselves or others, had proactive plans in place to reduce the need for restrictive practices, however, these were not always followed. Support did not always focus on people's quality of life and staff did not regularly evaluate the quality of support given, involving the person, their families and other professionals as appropriate
- People were not always protected from the risk and spread of infection.
Full details of the inspection are given in the report published on our website.
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