Kent PBS Service

The inspection was conducted following receipt of information from partner organisations of significant concerns regarding the safety of people. We conducted a focused inspection of the key questions Safe, Caring and Well-Led to assess these risks. The location was previously rated “Good” in August 2021. This has now changed to “Inadequate” following our inspection.

We identified 6 breaches of legal regulation in relation to person centred care, dignity and respect, safe care and treatment, safeguarding people from abuse and neglect, good governance and safe staffing.

We found people were living in unsafe and undignified circumstances, which placed them and others at greater risk of harm or deteriorating health. Risks were poorly managed with people having complex health or care needs that staff were not knowledgeable about, and people were not supported to make healthier choices to promote their own wellbeing.

There was a poor level of staff training and competence, with significant gaps in essential areas such as first aid, food safety and medicines management. We could not be assured that staff had been appropriately recruited.

Governance arrangements had not consistently identified areas of concern or ensured sufficient improvements were made. Documentation on how staff should support people was often significantly out of date or contradictory, and records of care did not clearly evidence how people were being supported in a way that met their needs or reflected best practices.

Incidents were not consistently learned from, and safeguarding incidents were not always appropriately reported in line with the providers responsibilities.

People were placed in situations where they had injured themselves or were in significant distress without being able to receive the medications they were prescribed, or medications had been administered in an unsafe way by staff who were not sufficiently knowledgeable on how to do so.

We assessed the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence and good access to local communities that most people take for granted. The service was not reflecting this guidance, and people were not treated with respect or as individuals. For example, people’s homes were described to be in a very poor state of cleanliness, and there had been inconsistent support to facilitate people meaningfully engaging with their own communities.

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 timeframe within which providers must improve the quality of the care they provide. 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.