A care home in Plymouth for people with learning disabilities, autism and/or complex needs has been placed in special measures following an inspection by the Care Quality Commission (CQC).
The inspectors found the care at Fairglen Residential Home to be unsatisfactory, after all five key questions – safe, effective, caring, responsive and well-led – dropped from good to inadequate.
A number of concerns were identified during the unannounced inspection, which led the CQC to take “immediate action to protect people from harm.”
Debbie Ivanova, CQC deputy chief inspector for people with a learning disability and autistic people, said there were not enough staff to keep people safe and staff didn’t have the right training to support people with complex needs.
“For example, two people living there had epilepsy, but staff had not received any training on how to manage an epileptic seizure. One person had regular hourly checks during the day, but these stopped at night when staff were sleeping.
“One person was prescribed urgent medicine to take if they were having an epileptic seizure, but staff didn’t know it was available until it was found by the inspection team. This put them at risk of prolonged seizures,” she said.
Ms Ivanova added that the registered manager did nothing to ensure that appropriate action was taken when incidents occurred.
For example, one of the 10 people living at the care home said they had been physically abused by a member of staff, and while the manager was aware of the complaint, they failed to report it to the local authority or investigate further.
Another person suffered an injury as a result of a fall and was taken to A and E, yet the manager failed to notify the CQC. Ms Ivanova described this as “very concerning”, given that the service was not learning from incidents or making improvements when things went wrong.
Staff were also heard using “disrespectful and outdated language” when talking about residents, and this type of language continued in their case notes. The inspectors say this meant people’s care was not person-centred and did not promote their dignity.
The culture of the care home was also found to increase people’s dependence on the manager and staff, and staff were not seen to encourage, support or empower people to make their own decisions or to develop life skills and increase their independence.
An example of this in the report is when a staff member took a person’s plate of food away from them without asking and then tipped half of its contents onto another person’s plate.
“We also found hand towels in the toilets and bathrooms had been bolted to the walls. The manager said this was because one person kept taking them. Instead of exploring this person’s sensory needs, restrictive measures were put on everyone living in the home,” Ms Ivanova said.
After the inspection, the CQC said it continued to seek clarification from the provider to validate evidence found.
They also looked at training data, policies and quality assurance records and spoke with four healthcare professionals, a representative from Plymouth City Council’s quality assurance and improvement team (QAIT) and safeguarding team and three relatives.
The care home will now be closely monitored and then re-assessed in six months’ time to ensure the suggested improvements have been made.
