Archived: Veilstone

On arrival we found that commissioning authorities had taken action to move people from the home due to ongoing safeguarding concerns and there were only three people present in the home. Two people moved out during our visit and the third person was due to move out that evening. Therefore we did not talk to any people who lived in the home as they were preparing to move and we were told that one person was particularly distressed. We only visited the main house and did not visit The Annex, The Stables or The Bungalow. We focussed our time on examining records pertaining to the care of two of the people who lived in the home and talking to six staff members.

Our examination of the records pertaining to two people who lived in the home showed that the model of care used in the home to manage people's behaviours and provide care and treatment was not based on good practice. This was because there were no person-centred planning processes in place and people were not involved in drawing up their own plans of care/support. People did not have health action plans and were not receiving annual health checks. Protocols for the administration of 'as required' medication were not comprehensive and continence issues had not been referred to the doctor or district nurse for assessment and investigation as to the possible cause. The risks associated with physically restraining people with particular health or medical conditions had not been assessed and there was no evidence that a medical practitioner had endorsed the physical intervention plan. Sensory assessments had not been carried for people with autism. There were no communication guidelines for people and no evidence of involvement from speech and language therapists.

The staff we spoke to knew what procedures to follow should an incident of mistreatment, abuse or neglect be witnessed, suspected or alleged. However we have received significant concerns regarding the care of the people in the home and have reported these as a safeguarding matter to be included in the ongoing safeguarding concerns which were being investigated by a multi-agency team.

Because all the people who lived in the home had moved out, or were in the process of moving out on the day we visited, the provider was not able to demonstrate compliance with the warning notices and we were not able to judge compliance. This was also the situation for the compliance actions made during our previous inspection. Therefore both the warning notices and compliance actions remain the same.

The provider has made a voluntary agreement not to admit any new people to live in the home whilst the safeguarding process continues. Should anybody come to live in the home we will revisit the location to carry out an inspection.

We also received information from the Local Authority that the registered provider, Atlas Project Team Limited, had applied for authorisation to deprive a person of their liberty. This application was not authorised as the Local Authority considered that the organisation could use alternative, less restrictive, methods. The registered provider had not notified us of this application nor of management changes within the home as they are required to do.

There are ongoing safeguarding concerns which are being investigated by a multi-agency team.

When we visited the home, on 12 and 23 October 2011, we only visited the main house and did not visit The Annex, The Stables or The Bungalow.

During our visit on 12 October 2011 we saw four of the people who lived in the home but did not talk to them due to their specific individual, behavioural and communication needs. The reasons for this were because the manager and a care worker told us that one person had been distressed the night before and one person's behaviour was unpredictable. The Nominated Individual told us that one person would not be able to effectively communicate with us and the other person only appeared briefly. Therefore we focussed our time on looking at the 'quiet room', talking to care workers, and examining records pertaining to the care of the people who lived in the home.

The main reason for the visit on 23 October 2011 was to check the use of the 'quiet room', therefore we were only in the home for a very short time.

We found that relatives, representatives/advocates and health/social care professionals had not been properly consulted or involved in 'best interest' decisions relating to people's care and treatment. This means there was no proper consultation and agreement that the way in which people's behaviours were managed in the home were in the person's best interests.

There were sufficient care workers on duty in the home who had the skills and training to ensure that people's health and social care needs were met. The care workers knew what procedures to follow should an incident of mistreatment, abuse or neglect be witnessed, suspected or alleged. However, through the safeguarding process, we have been informed that a staff member did not report an incident that was perceived by that person as abusive.

During our visit on 12 October 2011 we found that the 'quiet room' was not suitable for people to use as it did not have any heating and the design and layout did not protect people's rights to privacy, dignity, choice, autonomy and safety. Detailed risk assessments for each person on the use of the 'quiet room', including the use of a surveillance camera, were not available and the lack of these was putting people at risk of receiving care that was inappropriate, unsafe or excessively controlling. When we visited the home on 23 October 2011, one of the Directors told us that this room was no longer being used as a 'quiet room'.