Direct Approach Care Limited

We assessed the quality statements for the key questions of safe, effective, caring, responsive and well-led. We found the provider was in breach of the regulations in relation to safe care including safeguarding, governance and oversight, duty of candour and safety of the premises.

We assessed the service against ‘Right support, right care, right culture.’ This guidance supported judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choice, independence, and access to local communities that most people take for granted. We found the service had demonstrated an understanding of this guidance and were meeting them.

Improvements were needed regarding the safe management of medicines, safe transitions, risk management, safeguarding, lessons learned, positive behaviour support plans, recruitment, induction for staff, the safety of the premises, infection prevention control, duty of candour, and governance of the service.

People’s medicines had not been managed safely, lack of effective oversight of medicines had meant incorrect medicines had been administered to 1 person for a prolonged period.

Transitions between hospital and the home were not safe because the person’s needs were not reassessed when they returned to the service, and their medicines were not reconciled.

Risk management plans to guide staff in the use of physical interventions were not individually detailed, staff had received training but were not supported to know what specific intervention a person needed. People were at risk of harm from disproportionate and/or unnecessary restraint.

Opportunities to learn lessons to avoid reoccurrence of incidents had been missed because recording of safety incidents and staff debriefs were either not done or did not have sufficient detail to allow for analysis and review.

Recruitment practices were unsafe, recruitment files did not include the documentation required by the regulations. A sponsored staff was working beyond their permitted hours. New staff had not received the robust induction included in the provider’s policy.

Some aspects of the premises were unsafe; not all bedroom doors were fire doors or had intumescent strips. One bedroom door was missing. Some radiator covers were missing. One window did not have a restrictor in place, and it was possible to climb out of it. Cleaning chemicals were not stored securely. Regular legionella checks had not been recorded.

Some fire safety checks had been completed on a regular basis by staff, this included fire drills. Records relating to fire drills needed to improve to include who was present.

We observed poor infection prevention control (IPC) practices.

People, their families and other agencies had been involved in assessments and care planning. Reassessments and reviews had not always been done by the provider or had not been recorded. Care plans and risk management plans were in place but lacked some details necessary to sufficiently guide staff. Some staff were unable to access the risk assessments in the electronic care records and did not have access to paper records in the office.

Rotas showed people received the level of support they were assessed as needing. We observed sufficient staff to be on duty when we visited. People were supported to make decisions about day-to-day things such as clothing, food and drink and how they spent their time.

We observed staff were kind and respectful in their interactions. Staff spoke positively about the people they were supporting and were committed to enabling them to have a good experience.

People’s individual experiences, strengths and preferences had been recorded. People were encouraged to build on their skills and develop independence by staff.

People were responded to in a timely manner because the provider had developed communication guides for staff who understood how to recognise people’s verbal and non- verbal communication.

People received person-centred care and staff understood what was important for them. People were supported to access activities they liked in the community and in the home. People were supported to access care and treatment, and the provider sought to identify and overcome any obstacles to this.

Staff had access to an on-call system if they needed support out of hours. However, not all staff felt comfortable using this.

The registered manager’s oversight of the quality of care, care records, governance and the premises was either not in place or not robust enough to provide assurance the service was properly and safely managed. Leadership had not fully embedded the values of the service. Lack of clear guidance for staff in key areas of risk management and lack of candour in relation to safety incidents meant there was a risk of a closed culture developing.

Governance systems had not been followed; people were at risk of harm because the registered manager did not have effective oversight of quality issues. They did not identify the concerns we found during this assessment.

Staff gave us mixed views of the leadership in the home. While some staff felt confident a similar number of staff did not feel confident raising any concerns or issues with the registered manager because they did not feel they would be responded to appropriately. Staff did not feel free to speak up.

Some staff raised concerns about the registered manager using discriminatory language about staff. Some comments we heard during this assessment could have been seen to be discriminatory.

Feedback from other professionals identified concerns regarding the overall quality of management at the home. Three social workers identified it was often difficult to get clear information about health matters or documentation to support their assessments. During our assessment we found some difficulties accessing information we requested.

The registered manager made efforts to cooperate with the assessment process and acknowledged the concerns we had identified.

In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/ or appeals have been concluded.

We have asked the provider for an action plan in response to some of the concerns found at this assessment.