‘Inadequate’ care service in special measures after inspectors found vulnerable people ‘were at risk of avoidable harm’

A care service has been placed in special measures after inspectors found vulnerable people were ‘at risk of avoidable harm’.

The Elms, in Middleton, provides supported living and home care services to people with autism, learning disabilities and sensory impairments.

But a damning report from the Care Quality Commission (CQC) rates it as ‘inadequate’ – and says it faces being shut down if it does not make significant improvements over the next six months.

It comes after a series of inspections which discovered serious failings – including several breaches of care regulations – by the Milton Street-based service, which was first registered with the CQC in March 2021.

The watchdog found that people relying on its care ‘were not safe’ and ‘at risk of avoidable harm’.

The report adds: “People were not always safeguarded from abuse. We found a number of incidents and concerns that should have been raised with the local authority’s safeguarding team and had not been.”

Inspectors noted that, although safeguarding policies were in place and staff had received training, the appropriate procedures were not being followed.

“Referrals were not always made to the local authority safeguarding team when incidents relating to potential abuse had taken place,” the report adds.

Officials also found issues with consent.

In one building officials visited, there was CCTV in place in communal areas – but service users, families and staff members had not been consulted and consent/capacity assessments were not in place.

“The provider had failed to ensure appropriate consent had always been gained,” officials found. “This put people at risk of abuse.”

And while the service worked with a variety of health care professionals, not all necessary safeguarding referrals and CQC notifications were being sent.

This meant the registered manager was not working as closely with safeguarding and CQC as they should have been.

Inspectors also found that people were not always treated well.

While their privacy was respected, that was not always the case for their dignity and independence.

One person told how a staff member did not always communicate with them appropriately, while another described an outing being cut short and feeling that this was a ‘punishment’ for their behaviour.

When inspectors queried with the deputy manager they were told it wasn’t a punishment but that the person was ‘being silly’ and wouldn’t calm down so the staff thought it best to bring the person home.

Relatives’ feedback was mixed. Some people described staff as ‘kind and caring’, another relative described their loved one as ‘surviving and not thriving’.

However, officials did find some positive examples of how the service supported people’s equality and diversity by ensuring things such as specific diets were being followed.

But they were also concerned that people’s medicines administration records were not always being correctly completed.

“One person had been given an overdose of medication, which was not identified until two days later,” the report notes.

“It was stated that the staff member who caused the error would be retrained.

“However, they were not reassessed with a medication competency assessment and did not complete their medication training until two months later.”

The CQC noted breaches of five care regulations and also issued two warning notices.

It has requested an action plan from The Elms and will work with it and the local authority to monitor progress.

If the provider has not made enough improvement within the six-month timeframe and any part of the service is still rated as ‘inadequate’, enforcement action will be taken.

This means the CQC will begin the process of preventing the provider from operating the service – usually leading to cancellation or varying the conditions of the registration.

The maximum time for being in special measures will usually be no more than 12 months.

Rhombus Care, which runs The Elms, did not respond to a request for comment.

Nick Statham, Local Democracy Reporting Service