Archived: College Road

Updated 20 September 2019

The inspection:

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

The inspection was prompted in part by information of concern shared with us by the coroner and notification of an incident involving the death of a person using the service. This incident may be subject to criminal investigation and as a result this inspection did not examine the circumstances of the incident.

However, the information shared with CQC about the incident, including from the coroner, indicated potential concerns about the management of risk in the service including ligature risks. This inspection examined those risks and found sufficient action had not been taken to keep people safe.

Inspection team:

This inspection was carried out by one inspector and a specialist advisor with a specialism in mental health. A specialist advisor is a professional who assists us with current practice knowledge and expertise on inspection.

Service and service type:

The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided. The registered manager was not available during the inspection and had previously notified us of their absence.

What we did:

We reviewed information we had received about the service since the last inspection. This included any notifications we had received from the service and feedback we requested from external agencies including the local authority and Healthwatch. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England.

This inspection included speaking with two people, a professional involved in people’s support, two support workers, the service project lead (responsible for day-to-day management of the service), a deputy manager and the chair of the provider’s organisation. We also reviewed records related to two people’s care and record related to medicines management, health and safety and quality assurance.

Some information we requested was not available to view during our inspection, including the training matrix, recruitment files and incident records as we were told they were stored at the provider’s head office. Although we asked for this information to be sent by 48 hours after our inspection, the provider failed to ensure this was done and some information we requested was not available to support our judgements.

Updated 20 September 2019

About the service: College Road is a respite service offering accommodation and support for people with mental health support needs. Three people were supported at the time of the inspection.

People’s experience of using this service:

People told us they felt safe and satisfied with the service, and they felt that staff were supportive. People’s independence, choices and preferences were promoted. However, the provider had failed to ensure the quality and safety of the service with particular concerns as follows:

• The provider failed to take prompt and sufficient remedial action following the death of a service user in May 2018.

• Poor risk management in relation to people’s known needs, lone-working arrangements and the premises. Medicines management processes remained unsafe and staff were not supported in their roles.

• Please see more in Detailed Findings below.

Rating at last inspection: Good (January 2017)

Why we inspected: The inspection was prompted in part by information of concern shared with us by the coroner and notification of an incident involving the death of a person using the service. This incident may be subject to criminal investigation and as a result this inspection did not examine the circumstances of the incident. However, the information shared with CQC about the incident, including from the coroner, indicated potential concerns about the management of risk in the service including ligature risks. This inspection examined those risks and found sufficient action had not been taken to keep people safe.

Enforcement: We identified two breaches of the Health and Social Care Act (Regulated Activities) Regulations 2014 around safe care and treatment and governance. We also identified a breach of the Care Quality Commission (Registration) Regulations 2009. Details of action we have taken can be found at the end of this report.

Following the inspection we referred our concerns to the local authority responsible for safeguarding. In addition, we requested an action plan from the provider and evidence of improvements made in the service. We took urgent enforcement action due to our concerns about the safety of the service.

The overall rating for this registered provider is ‘Inadequate’. This means that it has been placed into ‘Special Measures’ by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve.

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration, if we have not taken this enforcement action already.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or varying the terms of their registration within six months if they do not improve and similar action may have been taken already. This service will continue to be kept under review and, if needed, could be escalated to further urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded. We will have contact with the provider and registered manager following this report being published to discuss how they will make changes to ensure the service improves their rating to at least Good.