The Care Quality Commission (CQC) has downgraded the overall rating for College House care home in Newton Abbot, Devon, from good to inadequate. It has placed the home into special measures to protect people following an inspection in December.
College House, run by Parkview Society Limited, is a residential care home which provides accommodation and personal care for up to 12 people, including autistic people and people with a learning disability. There were seven people living there at the time of this inspection, which was carried out as part of CQC’s routine monitoring of adult social care services.
Inspectors found seven breaches of regulations relating to providing people with person-centred care, safeguarding people from abuse and improper treatment, the unsafe environment, consent, safe care and treatment, safe staffing and the overall management of the service.
CQC has downgraded the areas of safe, effective and well-led from good to inadequate. Caring and responsive have dropped from good to requires improvement.
CQC has placed the service into special measures which involves close monitoring to ensure people are safe while they make improvements. Special measures also provides a structured timeframe so services understand when they need to make improvements by, and what action CQC will take if this doesn’t happen.
CQC has also begun the process of taking further regulatory action to address the concerns, which Parkview Society Limited has the right to appeal.
Stefan Kallee, CQC’s deputy director of adult social care for the South West, said:
“When we inspected College House, we found serious shortfalls in how the service was being managed, which undermined the efforts of staff to provide good care.
“It was clear that the service wasn’t assessing people’s needs well enough. The registered manager wasn’t aware of people’s specific learning disabilities, their mental capacity hadn’t been assessed, and staff told us they treated everyone the same. This meant people weren’t receiving care that was tailored to their specific needs and preferences.
“Leaders didn’t know enough about what was going on in the home and didn’t provide staff with the information, tools or support they needed to provide safe, person-centred care. For example, they didn’t ensure staff completed autism training, despite the home supporting autistic people.
“We were concerned to find that record keeping, systems and planning were all insufficient and staff confirmed they had to rely on verbal knowledge rather than written guidance. One person’s care plan lacked detail about their diabetes and how staff were to support them, increasing their risk of harm from diabetes complications.
“Leaders didn’t have a system in place to plan staffing levels and this meant there weren’t always enough staff to keep people safe. The registered manager told us that staff slept during night shifts and relied on people using their call bell to wake them up. However, one person receiving end-of-life care wasn’t able to use a call bell and was left overnight without regular checks, despite being doubly incontinent. This meant they couldn’t let staff know if they needed help or reassurance.
“We’ve told College House’s leaders exactly where they must make immediate and significant improvements, and we are monitoring the home closely to keep people safe while those changes take place.”
Inspectors found:
- Leaders didn’t ensure medicines were managed safely. Staff didn’t always sign medicine records and it wasn’t clear whether people were receiving their medicines according to their prescriptions, placing them at risk of harm.
- The service didn’t provide a safe environment for people. There weren’t tamper-proof restrictors on upstairs windows, meaning people were at risk of falling from height, and radiators weren’t covered to prevent burns. They hadn’t ensured legionella checks were completed, increasing the risk of harm from legionella-based contamination.
- The service restricted people’s access to meaningful activities and impacted their wellbeing. Both relatives and staff said people couldn’t go out often because there weren’t enough staff to facilitate this, including one person who had only been out twice in six months.
- Managers hadn’t sent feedback surveys for over a year, and there was little evidence of feedback being acted on. This meant the service didn’t consistently involve people and their families in decisions about care.