CQC publishes 36 reports from its review of services for people with a learning disability

25 April 2012

The Care Quality Commission (CQC) today publishes a further 36 reports from a targeted programme of 150 unannounced inspections of hospitals and care homes that care for people with a learning disability.

The programme is looking at whether people experience safe and appropriate care, treatment and support and whether they are protected from abuse. A national report into the findings of the programme will be published later this year.

These 36 inspections covered locations that provided a range of services including assessment and treatment, rehabilitation and longer term care.

Inspections were focused on two outcomes relating to the government’s essential standards of quality and safety: the care and welfare of people who use services, and safeguarding people who use services from abuse.

Inspectors found major concerns at five locations:

Assessment and Intervention Service (Birling Centre) – Kent and Medway NHS & Social Care Partnership Trust

Patients who use this service had their needs assessed and their healthcare needs met. However, information had not been used to plan care or manage people’s behaviours in a way that focused on their individual needs.

• We have received an action plan from Kent and Medway NHS & Social Care Partnership Trust. Most of the actions are to be completed by 31 May 2012.

9 Victoria Street – Derbyshire County Council

People did not have up to date and specific information about the service. This meant they could not make an informed choice about using the service.

There were no plans in place to ensure people had the right support to move on to more independent living.

Care plans, including behaviour management plans, lacked detail, or were missing, and were not reviewed regularly to ensure that people’s needs were met.  People were not consistently involved in a person centred way in their personal support and health care. People’s health care needs were not effectively assessed and monitored.

There was a lack of structured and meaningful activities to meet people’s needs and to maintain and improve their independent living skills.

• We have received an action plan from Derbyshire County Council and expect most actions to be completed by the end of July.

Elmsmead – Voyage Limited

People’s needs had not been re-assessed when they transferred between services within the organisation. This could lead to people being placed in a service where their needs could not be met.

There were no records to show that potential new admissions to the service were considered against the needs of the people already living in the service.

Care planning was poor in some cases with plans not being person centred, produced in an easy read format, not being reviewed at regular intervals and not giving the reader enough information to meet the person’s needs.

Not all of the risk assessments we saw provided enough information to minimise potential risks to peoples safety.

The strong smell of urine was of concern with the potential implication that people’s continence was not being managed effectively.

• We have received an action plan from Voyage Limited showing how it will make the necessary improvements at  Elmsmead.

Cheswold Park Hospital – Riverside Health Care

Overall, systems to prevent and identify abuse were not adequately robust to ensure patients were always effectively safeguarded. Some staff were confused about the safeguarding procedures. Staff had not responded appropriately to an allegation of abuse or made an `alert’ in a timely way. The systems in place to support patients following physical interventions (restraint) were not robust or always followed and this meant that patients at Cheswold Park Hospital were not always protected from abuse, or the risk of abuse and their human rights were not always respected and upheld.

• We have received an action plan from Riverside Health Care showing how it will make the necessary improvements in respect of Cheswold Park Hospital.

Willes Road– Turning Point

Incidents of possible harm had not been dealt with according to safeguarding policy and procedures and this was placing people using the service at risk of harm to their well being.

Staff did not fully understand how the best interests of people using services should be protected through the Mental Capacity Act and Deprivation of Liberties Safeguards.  When this happens people cannot be sure they will be protected from possible harm to their safety and well being.

• CQC has received a satisfactory action plan from Turning Point. Safeguarding concerns are now being reported and investigated in accordance with the local safeguarding agreement and CQC is being notified of these.

All the services where concerns are identified have to tell the CQC how and when they will improve. Those failing to meet essential standards could face enforcement action by the regulator if improvements are not made.

Overall, 11 locations are compliant with Outcome 4, 13 have minor concerns, nine have moderate concerns and three have a major concern. On Outcome 7, 16 locations are compliant, five have minor concerns, 13 have moderate concerns and two have a major concern.

The batch contains 10 NHS, eight independent health care and 18 adult social care locations.

CQC inspectors were joined by ‘experts by experience’ – people who have first hand experience of care or as a family carer and who can provide the patient or carer perspective as well as professional experts in our learning disability inspections.

Where inspectors identified concerns, they raised these immediately with the providers and managers of services.

The national report will be based on the findings from all the 150 inspections and will make conclusions about the overall state of this type of service.

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Notes to editors

For media enquires call the CQC press office on 0207 448 9401

For general enquiries call 03000 616161

The reports will be published on CQC’s web site on Wednesday 25 April. http://www.cqc.org.uk/LDReports7

The reports published today are for the following providers and locations. The table shows our findings in relation to the two outcomes we focussed on, but some reports also show concerns in respect of other outcomes.

Amendment to CQC inspection report regarding Shear Meadow (Press Release 4 April 2012)

Our report on Shear Meadow published on 4 April, and highlighted in our press release issued on the same date, contained an error in the level of concern noted for Shear Meadow (Cambian Learning Disabilities Limited); it should be moderate not major for Outcome 7 as was detailed in the report and on the press release.

There are no other changes to the report and a revised version will be loaded to the website. The CQC apologises for any inconvenience this may have caused.

Inspection teams are making unannounced visits to 150 services. More than 100 are NHS and independent services that provide services such as assessment and treatment, rehabilitation and longer term care. The others are adult social care locations.

They are checking two outcomes:

• Outcome 4 Care and welfare
• Outcome 7 Safeguarding adults from abuse.

But where our inspectors find problems with other outcomes, they will report on these.

Our inspection teams are led by CQC inspectors joined by two ‘experts by experience’ -  people who have experience of using services, either first hand or as a family carer and who can provide the patient perspective and a professional advisor.

CQC set up an advisory group to help it plan the programme. CQC’s Chair, Dame Jo Williams, chairs the group. The members come from a range of voluntary, charitable and other organisations that work with or represent people with learning disabilities and their families.

The learning disability inspection programme was launched in response to the abuse revealed by undercover filming by the BBC Panorama programme. CQC apologised for failing to respond to warnings of abuse at Winterbourne View. Matters concerning Winterbourne view are the subject of serious case review.

 

Further information

There is information on this website about How to share concerns and complaints about a social care service, a council, independent healthcare services, the NHS or CQC.

People can telephone concerns to CQC on 03000 616161

The Challenging Behaviour Foundation has provided this list of organisations providing independent support to families with disabled relatives. Click on the name of an organisation to read more information.

Support for families

Families provide long-term love, care and support for their disabled relatives, and speak up for them. Even when people leave home, they do not leave the family. Families continue to offer a lifetime of involvement and support, and know a great deal about their relative’s needs and wishes, likes and dislikes.

When the services and support for a relative go wrong it can be very difficult for families to deal with. They may be faced with a barrage of information and decisions to take, as well as coming to terms with what has happened. It is important that families know where they can get impartial information, and find out what support is available to them. There is a list below of organisations which you may find useful.

It is important to note that family carers must be consulted and involved in key decisions about the care and support of a relative who is unable to make these decisions (unless you have specifically asked not to be involved). There is a proper legal process that must be followed, under the Mental Capacity Act 2005. For example, your relative cannot be moved to another service without involving you, and others who know your relative well, in the decision-making process. For more information about this, see Making Decisions: A guide for family, friends and other unpaid carers. Copies available by phoning 0300 456 0300.

Organisations providing independent support

Other useful contacts