Harper house - Wolverhampton

Risks associated with choking and environmental risks were not managed safely, placing people at risk of significant harm. This included the risk of choking and the risk of accessing hazardous items, fire, infection and falling from height. Medicines were not always managed safely, and people were not consistently protected from the risks associated with ‘as required’ medicines prescribed to help manage distressed behaviours.

Staff were not always aware of which people had lawful restrictions placed upon them as a result of Deprivation of Liberty authorisations. Lessons were not always learned as a result of safety incidents and an effective tool to identify safe numbers of staff was not in place. Some people’s opportunities to access the community at the times they wished to do so was restricted due to staffing levels.

People’s care, treatment and support was not always effectively assessed, planned, monitored and reviewed to ensure they received safe care and achieved good outcomes, and there was no evidence to show people were involved in this process. We could not be assured that people consistently consented to some restrictions placed upon them when they had the ability to make decisions about their care.

People did not always feel they were treated with kindness, staff did not always describe people and their needs in a dignified manner, and individual preferences were not always met.

Leaders and the culture they created did not always support the delivery of safe and effective care, and staff did not always feel they could speak up about safety concerns. Governance systems were not always effective at assessing, monitoring and improving the safety and quality of care provided.

However, staff were safely recruited and understood how to identify and raise safeguarding concerns. Staff understood how to assess people’s ability to make decisions about their care, and supported people to receive care in their best interests when they were unable to make decisions about their care. People’s communication needs had been assessed, and staff knew how to support people to communicate effectively. With the exception of dietary care plans, care plans were sufficiently detailed and personalised to each individual. People’s end of life care preferences had been sought and recorded.

We identified 2 breaches in regulation relating to safe care and treatment and good governance. Due to the seriousness of the concerns, we urgently imposed conditions onto the providers registration in order to safeguard people.

This service is being placed in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a time frame within which providers must improve the quality of the care they provide.

Following our inspection, the local authority intervened and supported all people who lived at the service to move to alternative accommodation and services. Therefore, the service became dormant. The provider is required to notify us if they begin delivering a regulated activity again. If a service remains dormant for 12 continuous months, the CQC may begin the process of cancelling the provider’s registration.