Archived: Georgian Annexe

Updated 3 November 2017

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 25, 26 and 28 July and 2 August 2017: the first day was unannounced. Two adult social care inspectors undertook the inspection on the first three days, and one adult social care inspector completed the inspection on the fourth day. Prior to the inspection we received information from Torbay and South Devon NHS Foundation Trust about three safeguarding concerns in relation to people living at this service. These related to punitive and restrictive practices within the home and people not receiving safe care and support.

Before our inspection, we reviewed other information we held about the home. This included correspondence we had received and notifications submitted by the service. A notification must be sent to CQC every time a significant incident has taken place, for example where a person who uses the service experiences a serious injury. We asked the provider to complete a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. The PIR was completed and returned in June 2017.

During the inspection we met seven people and spoke with four people in detail about their care. Some people said they did not wish to speak to us. Some people made very negative comments about the service which we have not included in this report but passed to the relevant health and social care professionals. We spoke with the provider and registered manager and ten care staff including members of the management team. We looked at seven people's care records, seven staff recruitment files, records relating to staff training and supervision, medication administration records and other records relating to the management of the service. We reviewed some CCTV footage, however we were informed that CCTV footage was not available prior to 29 July 2017 as following an upgrade to the service, the footage had been mistakenly erased. We observed people and staff throughout the inspection and saw how people were being supported.

During the course of the inspection we attended two safeguarding meetings held by Torbay and South Devon NHS Foundation Trust and spoke with health and social care professional involved in the care of all those living at Georgian Annexe. As a result of our inspection findings we made three safeguarding referrals to the Trust.

Updated 3 November 2017

This inspection took place on 25, 26 and 28 July and 2 August 2017. The first day of the inspection was unannounced. This was the first inspection of Georgian Annexe since it registered with the Care Quality Commission (CQC) in August 2016. Georgian Annexe is a purpose built residential home, which can support up to 14 people. All bedrooms are en-suite and one room is self-contained with kitchen facilities. Lifts provide access to all floors.

The inspection was prompted in part by information received from Torbay and South Devon NHS Foundation Trust about three safeguarding concerns in relation to people living at this service. These related to punitive and restrictive practices within the home and people not receiving safe care and support. These incidents are subject to further investigations by other authorities and as a result this inspection did not examine the all of the circumstances of these incidents.

However, the information shared with CQC about the incidents indicated potential concerns about unsafe and improper treatment of the people living at Georgian Annexe. This inspection examined those risks.

Georgian Annexe is registered to provide personal care and accommodation for up to 14 adults who require support with their mental and physical health. At the time of the inspection, 12 people, one of whom was a younger person under the age of 17years, lived at the service. The service’s registration with CQC did not support the admission of people under the age of 17years. Following the inspection, this young person was moved to alternative care provision.

The service had a registered manager in post who was also registered to manage another of the provider’s services. 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. Following the inspection, the registered manager submitted an application to CQC to cancel their registration.

The provider and registered manager failed to ensure the systems and processes in place were effective in ensuring the service is compliant with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. During the inspection we identified a number of breaches of the regulations including those relating to a safe environment, protecting service users from harm and improper treatment, mitigating risks to service users health and safety, insufficient staffing levels and the quality of information and guidance contained within service users’ care and support plans.

Lack of supervision and oversight of staff practices within the home failed to identify the restrictive and punishing practices used by staff to manage people’s behaviour. The service did not have effective systems in place to assess and plan for people’s care needs or to monitor staff competence and skills to carry out the tasks required of them. The provider and registered manager failed to notify the CQC of significant incidents affecting people’s health, safety and well-being.

Immediately following the inspection, as a result of the interim outcome of the safeguarding process, the provider appointed a Care Consultancy Service to support the management team. We also asked the registered manager and provider for an urgent action plan to be put into place to mitigate the immediate and serious concerns we had identified. This was received on 3 August 2017. On 4 August 2017, we imposed conditions on Georgian Annexe (Torquay) Ltd registration. These included preventing Georgian Annexe from taking any new admissions, to ensure staffing levels were as contracted, to ensure the service met fire safety regulations and to report weekly to CQC the actions taken by the provider and the Care Consultancy Service to ensure people’s safety. CQC will review these weekly reports to identify if risks to people’s health, safety and welfare are being appropriately managed.

People living at Georgian Annexe were not receiving safe care and support. We identified a number of significant concerns in the way people were being supported. These included how staff supported people to manage risks associated with their behaviour; staffing levels in the service both during the day and overnight; the safety of the environment with regard to fire precautions and how medicines were being managed. During the inspection we made safeguarding referrals for three people to Torbay and South Devon NHS Foundation Trust (the Trust). We attended two safeguarding meetings on 26 and 31 July 2017 to review the safety and wellbeing of the people living at the service. Following the first meeting, the service was placed into ‘whole service’ safeguarding by the Trust which meant they had concerns about people living at Georgian Annexe. As a result health and social care professionals commenced urgent reviews of each person’s care and support needs and whether these were being met at Georgian Annexe.

Many of the people living at Georgian Annexe had needs in relation to their mental health conditions, including obsessive and compulsive behaviour, depression and suicidal thoughts and behaviour which placed themselves and others at risk of harm. Assessments to identify these risks were either insufficiently detailed to guide staff about how to support people to mitigate risks, or where detailed information was provided, this was not being followed by staff.

People were not protected from the use of punitive, threatening and improper treatment. The service was using a document called responsive support plans to guide staff with the support of people’s behaviour. These plans had been written by a member of staff who had no specialist knowledge people with complex mental health needs. Staff referred to these plans as ‘traffic lights’ as they described people’s behavior in terms of “green”, “amber” and “red”. The plans were excessively restrictive and did not provide clear rationale for staff about how they should respond to service users’ behaviours. For example, people would have their furniture removed from their rooms or face other restrictions such as having to remain in their rooms. Staff used this system to threaten people with the consequences of moving into the ‘red’ area of their responsive support plan.

People rights under the Mental Capacity Act 2005 were not respected. People’s consent to receive care and support had not been recorded and people’s capacity to make decisions about their care and treatment were not properly assessed. Some people were potentially having their liberty unlawfully restricted with the use of locked external doors and no way to exit with building without staff agreement. The service used closed circuit television (CCTV) in the majority of communal areas around the building. People’s consent to the use of this had not been recorded and some people’s privacy was breached as the cameras gave a view directly into their bedrooms.

Staff used disrespectful and de-personalised language when talking about people’s wellbeing. Rather than refer to how people were feeling or how they were managing their anxieties and behaviours, staff referred to them as a colour on their traffic light system. We heard staff refer to people as being on ‘red’ or on ‘green’. Staff also used unprofessional terms in people’s care records. Staff described people as being in a good or bad “headspace” in their daily care notes without describing what this meant for the person. Without this description people’s care and support plans cannot be reviewed and amended to be more personalised and reflective of their needs.

Insufficient numbers of staff were employed at the service to ensure people received safe care and support and to meet the contractual staffing arrangement made by the commissioning authorities. Staff told us they did not have the training or skills to support people with complex mental health needs. One member of staff told us, “People are not safe and neither are the staff. There aren’t enough staff and we are not trained.” With the exception of one day’s training in challenging behaviour and breakaway techniques and another in physical intervention, staff had received no training specific to the needs of those people living at Georgian Annexe. Staff were not provided with supervision or support in their role. Although staff told us they were able to speak to members of the management team, there was no evidence staff were provided with formal supervision or appraisal of their work performance or training and development needs.

People could not be assured they would receive their medicines as prescribed. One person had not received a prescribed medicine to help manage their mental health condition for five days and another person did not receive the correct dose of a prescribed medicine on four occasions. Although neither person suffered undue consequences, this demonstrated staff were not managing people’s medicines safely.

Care plans and responsive support plans (traffic light system) failed to provide staff with information and guidance about how to promote people’s positive behaviour as part of an approach in reducing people’s self-harm or aggressive behaviour. There was a lack of strategy to teach and support people to develop skills so they could develop less harmful ways of communicating their needs.

People told us they did not always receive the care and attention they needed from staff to promote their independence. Where people had identified personal goals to achieve while living at Georgian Annexe, there was no evidence people received support to achieve these goals. Care plans provided no information for staff about how to support their independence. People at risk of social isolation were not being supported to b