We had information from a variety of sources about concerns at the service. On 2 October 2014 five inspectors and two BSL (British Sign Language) Interpreters inspected the service. We were made aware of further concerns so three inspectors returned and carried out a second inspection on 14 November 2014. At this inspection we visited two of the nine houses at the service. During these visits we were able to answer our five questions;
Is the service caring?
Is the service responsive?
Is the service safe?
Is the service effective?
Is the service well led?
Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, talking to staff, the provider and from looking at records.
If you want to see the evidence supporting our summary please read the full report.
Is the service safe?
The service was not safe.
People were not protected from harm and abuse. Staff used punishments including withdrawing activities to manage behaviour that was challenging.
Restrictions were imposed without regard to people's capacity and their ability to agree or disagree with the restrictions.
Risks were not always assessed and managed placing people at risk of harm.
People were at risk from staff who did not have the skills and knowledge to meet their needs. Staff were not properly supervised.
Medicines were not always managed and administered safely.
Staff had been vetted and checked.
Is the service effective?
The service was not effective.
There were gaps in training so staff were not trained in essential subjects as well as more specific subjects including sign language.
People were not fully involved in making decisions about their care.
People's capacity was not assessed and they were not always given the opportunity to consent to the care being given.
Is the service caring?
The service was not caring.
Not all staff were considerate and respectful to the people they supported and to each other.
People were at risk of discrimination.
Choice making was limited due to staff inability to communicate with some people. Staff made choices for people rather than with them.
Is the service responsive?
The service was not responsive.
People did not always receive the one to one support they had been assessed as needing.
Care plans and behavioural plans lacked detail and updates so staff did not have clear guidance on how to give the right support.
When concerns were raised they were not always acted on.
Is the service well-led?
The service was not well led.
The culture of the staff was not inclusive and open but one of control.
Staff practice had gone unchecked and had been abusive at times.
There was not good leadership or management over the nine houses.
Audits and checks were infrequent and unreliable. There was no overall scrutiny of staff practice.
Procedures had not always been followed leading to continued risks.