Archived: Gate House

Gate House is a residential care home providing accommodation and personal care to four people with a learning disability at the time of the inspection. The service can support up to seven people.

People’s experience of using this service and what we found

People were not protected from harm and were at risk of abuse from other people and staff. People had been unlawfully restrained by staff. Staff did not have the skills or competencies to support people when they were distressed or to support them proactively to manage their behaviours. Incidents were not reported to the relevant professional stakeholders. The provider had failed to introduce additional measures to reduce repeated incidents or learn lessons. The registered manager and provider had poor oversight of incidents and had allowed people to be harmed by one another and staff.

There was a poor culture within the service which was not person centred. People were restricted in their home, for example they were not allowed in certain areas of their home and could only have snacks at specific times of the day. Staff, the registered manager and provider were not open, honest or transparent when things went wrong. The registered manager and nominated individual failed to meet their regulatory requirements.

People’s views had not been sought since they moved into the service, they were not encouraged to plan their care or make decisions about the service. The providers systems for overseeing the service were ineffective and not robust.

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 and in their best interests; the policies and systems in the service did not support this practice.

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. Right support, right care, right culture is the guidance CQC follows to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

The service was not able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture.

Right support:

The model of care setting did not maximise people’s choice, control and Independence.

Right care:

Care was not person-centred and did not promote people’s dignity, privacy and human Rights.

Right culture:

Ethos, values, attitudes and behaviours of leaders and care staff did not ensure people using services could lead confident, inclusive and empowered lives.

This meant people were placed at harm; had unnecessary restrictions placed on them and did not receive person centred care. The provider had not acted or taken any measures to mitigate the risk of harm to people or support people to live with choice or independence.

Following this inspection we worked closely with Local Authorities to ensure people were safeguarded from on-going harm. Three people were supported to move out of Gate House. There is currently no one living at Gate House.

Immediately following this inspection the nominated individual of this service changed.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was Good (published 13 December 2019).

Why we inspected

We received concerns in relation to incidents and allegations of abuse. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We reviewed the information we held about the service. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from Good to Inadequate. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvement. Please see the safe and well led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Gate House on our website at www.cqc.org.uk.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to safe care and treatment, safeguarding, staffing, good governance, and notifications of other incidents at this inspection.

Following the inspection, we took immediate action to restrict admissions to the service. We took action against the provider and cancelled their registration at Gate House. Everyone moved out of the service and Gate House is now closed.

Gate House is a purpose-built residential care home providing accommodation and personal care to six people with a learning disability. The service can support up to seven people.

The service has been developed and designed in line with the principles and values that underpin Registering the Right Support and other best practice guidance. This ensures that people who use the service can live as full a life as possible and achieve the best possible outcomes. The principles reflect the need for people with learning and physical disabilities and/or autism to live meaningful lives that include control, choice, and independence. People using the service receive planned and co-ordinated person-centred support that is appropriate and inclusive for them.

People’s experience of using this service and what we found

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

The service applied the principles and values of Registering the Right Support and other best practice guidance. These ensure that people who use the service can live as full a life as possible and achieve the best possible outcomes that include control, choice and independence.

The outcomes for people using the service reflected the principles and values of Registering the Right Support by promoting choice and control, independence and inclusion. People's support focused on them having as many opportunities as possible for them to gain new skills and become more independent.

People appeared happy and relatives told us they were pleased with the care and support received. A relative told us, “I take my hat off to the staff, they work in a sometimes difficult environment and they always do it with kindness and a smile”. Staff were friendly and attentive to people’s needs and our observations showed there were enough staff to meet people’s needs. Staff were trained and felt supported.

People felt safe and staff were aware of how to promote people’s safety. Regular checks were in place to ensure staff worked in accordance with training and health and safety guidance adhered to.

The environment had plenty of communal space for people to enjoy. People enjoyed the activities that were provided, staff told us there were many opportunities for people to go out and people were living fuller lives. A relative told us, “[Registered manager] has even got [my relative] going to the gym regularly. I’m amazed, he’s never liked exercise. They really know how to motivate him”.

People were involved in planning their care and their views and preferences were acted upon. Feedback about the registered manager and staff team was positive. There was an open culture in the service and an expectation that people were supported in a person-centred way. Staff were clear about their roles and the management team engaged well with the team and other agencies.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

The last rating for this service was Good (published 15 June 2017). At this inspection the service has remained rated as Good.

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The service is in the village of Eastry near to the main towns of Sandwich, Dover and Ramsgate. There was one person living at Gate House and two people who were about to move in. Each person had their own bedroom. The home is open plan in style with access to the garden at the front and back of the house. The house has one level and is set in the grounds with other houses owned by the company. The houses are separated by fencing and gates for privacy and security.

There was a registered manager at the service who was present on the day of the inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At our last inspection in January 2016, the service was in breach of some of the regulations and was rated ‘Requires Improvement’. The registered manager sent us an action plan outlining how they would rectify those breaches. The registered manager and team had worked hard to update policies, care planning, staff training and recruitment and develop communication support and person centred care. At this inspection improvements had been made and all the regulations were met.

The service had a clear direction and purpose that the staff team were signed up to. There was a person centred culture. Staff were enthusiastic in their roles and had received training to make sure they had the necessary skills to support people to keep them healthy and well minded.

A relative told us, “The main thing I look for is honesty and I feel confident in the leadership at Gate House.”

Thorough and detailed assessments were carried out with people and their representatives before they moved into the service. The registered manager made sure that people were compatible with each other and that sufficient preparation had been made to give people the best chance of success. The service went the extra mile to make sure people’s rooms were designed in the way they wanted and organised equipment and made adaptations with people’s preferences and individual needs in mind.

Staff were caring and people’s individuality was respected and nurtured. People’s confidence was growing and with this their communication skills had increased. Relatives and health and social care professionals told us that the service was really making a difference to people’s lives. People had more control over how they wanted to live their lives and were trying new experiences. People were more confident and incidents of anxious behaviour were reducing with the change of lifestyle. There were planned activities that people could choose from and the right number of staff to support them.

There was a system of risk assessment to protect people as much as possible without limiting their experiences. Each situation and opportunity was assessed for how it would enhance the person’s quality of life and what the potential risks were. Positive risks were taken to help people develop their independence.

People were learning new skills and living as active a lifestyle as they wanted. Staff respected peoples’ privacy and dignity and offered people choices in the way they could understand and respond to. Meetings were held regularly with people to plan and discuss their goals and aspirations so that the service was run in the way they wanted. People’s relationships with their families and other people who were important to them were encouraged and supported; this included regular phone calls and visits.

People were supported to maintain a healthy active lifestyle. Clear easy read plans were designed to help people manage health conditions that needed monitoring. The staff worked closely with health professionals to maintain peoples’ health and followed their advice. Medicines were stored safely and managed safely by the staff. Prescribed medicines had been reviewed and there were regular audits of stocks and administration.

Mealtimes were organised in the way each person preferred. People made their own meals as much as possible and were encouraged to eat a healthy diet. The kitchen was practically designed with everything accessible and there were comfortable dining areas for people to eat either together or on their own if they preferred.

The registered manager understood the principles of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). People were subject to constant supervision by staff and there were some restrictions to their liberty but these had been assessed to make sure they were the least restrictive. For example, people were able to freely access the kitchen and only sharp knives and other assessed items were kept out of harm’s way. All DoLS authorisations had been agreed and were up to date or had been sent to the local authority for review.

Staff we spoke with knew about different types of abuse and had attended training in safeguarding people from harm and abuse. Recruitment checks on staff were thorough. References were requested and any issues were followed up. Health declarations had been completed and prospective staff had provided proof of their qualifications.

Staff had regular team meetings and one to one meetings with the registered manager or senior members of the staff team and said they felt well supported and were able to air their views.

There was a clear complaints procedure and opportunities for people to share their views and experiences of the service in a way they could understand. An easy read version had been designed and was available to people.

Regular checks of the environment had been carried out and there were records of checks of the care plans, staff files, medication records and other records. There was a quality monitoring system in place. The current service was fairly new and people were only just starting to move in. People’s and their representatives views had been gathered as part of the assessment process at this time. Incidents and accidents had been analysed to look for any common patterns and trends to reduce further incidents. The registered manager had notified the CQC of events that affected people or affected the smooth running of the service. The office was well organised and records were accessible and up to date.

The service is in the village of Eastry near to the main towns of Sandwich, Dover and Ramsgate. There were four people living at Gate House and one person who stayed for weekends. Each person had their own bedroom. The home is open plan in style with access to the garden at the front and back of the house. The house has one level and is set in the grounds with other houses owned by the company. The houses are separated by fencing and secure gates.

There was a registered manager at the service who supported both days of the inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The registered manager started working at the service in August 2015. He had identified lots of areas where improvements were needed and had written an action plan. An acting deputy manager had been supporting the manager and a new deputy manager had just started and was going to be based in Gate House.

At the time of the inspection the home provided an unpredictable and unsettled environment for people. There was an inconsistent approach to supporting people that sometimes put people’s wellbeing at risk. There had been some changes in the service provided and some new people had moved into Gate House. People did not all get along and they had conflicting needs that made it difficult for staff to manage and support people effectively. The registered manager and deputies were trying to sort the service out, but were managing various situations that occurred in order to protect people, rather than being able to manage the service and prevent the situations from occurring in the first place. The registered manager and deputies had lots of ideas to improve the service and were working through the action plan, which meant that some of their ideas had not yet been implemented.

Risk assessments had been carried out for general areas of risk and were in people’s care plan folders. These covered areas like slipping in the bath or needing support to go out due to a lack of understanding of road safety. Risk assessments for the current difficulties and needs were being assessed on an almost day to day basis, so they were not all recorded clearly in people’s plans. In these circumstances, staff were reliant on senior staff and management to direct them to protect people.

Staff we spoke with knew about different types of abuse but not all of the staff had attended training in safeguarding people from harm and abuse. Recruitment checks on staff were not as thorough as they should be. Some staff did not have the right number of references and gaps in their employment history and this had not been followed up. Staff had not declared that they were healthy and fit for the role and provided proof of their qualifications.

There were sufficient staff to meet people’s basic care needs. People’s unpredictable behaviours meant that at times a higher staffing level was needed. Recently the staff had been organised so that they supported people with individual activities to minimise the risk of behaviour that may harm others.

Staff attended basic training courses; subjects related to peoples’ needs were limited. Staff had not had training in person centred planning, learning disability awareness and positive behaviour support. Staff had not had the opportunity for regular one to one meetings. The registered manager agreed that the training for staff could be improved and he would talk to the provider about this. Staff we spoke to were motivated, enthusiastic and willing to learn. There had been some recent staff meetings and staff said they felt supported by the new manager and deputies.

Staff respected peoples’ privacy and dignity and, on the whole, were kind and caring. There had been significant changes in the service and staff were getting to know people. People were laughing with the staff when carrying out some of the activities. Some of the time staff responded well to people’s ways of communicating but people’s communication was not consistently supported. There were no communication systems in place despite involvement with speech and language therapists and communication aids being designed in the past for people. The home environment did not support communication, giving people some control. For example, there was nothing to show who was on duty that day, what the activity options were, what the meal choices were and what other opportunities were on offer.

People needed more support to manage their independence and have more control over their lifestyle. Each person had a care plan detailing their needs. Personal goals and aspirations had not been recorded so there were no plans to help people achieve their goals. There were no plans to support people to learn new skills and to develop existing skills like, learning more about money, cooking or how to do laundry. The registered manager was aware of this and wanted to improve this. Some care plans had not been reviewed so it was not clear if the support being given was effective.

People had their nutritional needs assessed and some people had specialist diets. Some of the support needed for this was complicated and the guidelines were confusing. Not all staff were confident with this and records were inconsistent or missing. Each person had a health action plan that gave staff details about the person’s health needs. The staff worked closely with health professionals to maintain peoples’ health and followed their advice. Medicines were stored safely and managed by the staff. The potential for people to take some control of their medicines had not been assessed.

The registered manager understood the principles of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). People were subject to constant supervision by staff and restrictions to their liberty, for example, some external doors were locked and access to the kitchen was restricted. DoLS authorisations had been agreed by each person’s local authority and had been reviewed within the right timescales. Restrictions were being reviewed to make sure that they were the least restrictive option.

The house was generally clean and spacious but did not feel homely and was in poor repair. Work was planned for refurbishment. People had their own bedrooms that were personalised. Some people were choosing new furnishings and pictures. People usually chose to eat together in the main room dining area and looked like they enjoyed the food. There were two vehicles for people to use to get out and about in the local area and to access a variety of activities. Staff were finding out about people’s interests and provided a variety of activities. These needed to be developed to make them more purposeful. People were supported to maintain relationships with people who were important to them.

The registered manager was in the process of moving offices and was based in one of the other homes in the grounds. A deputy manager had been employed and was based in Gate House. The deputy manager was reorganising the rooms so that they had a separate office to work from. Records had been moved and some were incomplete or missing.

There was a lack of records relating to checks and audits. Regular checks of the environment had been carried out but not acted on. There were no records of checks of the care plans, staff files, and other records. After the inspection the provider advised us that audits of these records had been carried out. We will check this at our next inspection. Peoples’ and stakeholders, including staff’s, views had not been gathered, analysed and acted on. After the inspection the provider told us that surveys had been sent out to relatives and carers in July 2015 and to staff in October 2015 and that feedback had been given to the service. Recently, some incidents and accidents had been analysed to look for any common patterns and trends but there was more work to be done with this to reduce further incidents. The registered manager agreed that this was an area for improvement.

There was a complaints procedure but it was not displayed. There were plans for an easy read format of the complaints procedure but this was not yet in place. The registered manager had notified the CQC of events that affected people or affected the smooth running of the service.

At this inspection we found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see details of the breaches and the action we have taken at the back of this report.

People were assisted to attend health care checks and community health professionals were involved to provide advice and support when needed.

We saw people looked comfortable and at ease in the home and with staff. There were procedures in place for staff to follow to protect people from abuse.

The home was maintained and checks were in place to make sure it provided a safe environment for the people who lived there. There was a maintenance and refurbishment plan in place. Some redecorating had commenced and work to refurbish the kitchen had been organised.

There had been some staff changes but there were sufficient staff to support the people who lived at the home. Training that the manager had identified the team needed was being organised. Staff were being supported and directed by a new manager to develop their confidence and skills to effectively meet the needs of the people using the service.

At the time of our inspection the provider did not have a registered manager in post.

People received support to maintain a healthy, active lifestyle. They were able to pursue a variety of hobbies and interests in the home, at the day centre and out in the community. People were assisted to attend health care checks and community health professionals were involved to provide advice and support when needed. A healthy balanced diet was offered to people who were able to choose the food they ate from photos or food packets if they did not understand the menu. People were supported to develop their independence skills, including making snacks and drinks.

People were assisted to express their views and make important decisions because the staff helped them with their communication and spent time with them.

There were a clear recruitment process and staff said they received the training they needed and were well supported when starting work in the service.