KEPA Care Solutions Limited

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We found two breaches of the legal regulations in relation to good governance and notification of other incidents. The oversight of the service was poor and ineffective. Audits completed by the registered manager and senior staff failed to identify the serious and widespread concerns identified within this assessment. There was a closed culture at the service which the registered manager and senior staff failed to identify and improve. The registered manager and senior staff did not have the knowledge on how best to support people with a learning disability, and autistic people. Key guidance and legislation in relation to supporting people with a learning disability, and autistic people was not followed. The registered manager and senior staff missed opportunities to learn from incidents and accidents.

This service scored 32 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Although staff told us there was a positive culture within the service, we found this was not the case. Staff did not advocate for people, to be involved in decisions about their life, and restrictions placed on them. The registered manager and staff failed to identify that staff were not always respectful and kind when referring to people within daily notes. For example, one person’s daily notes mentioned that they had been, ‘on their best behaviour most of the time’ this is not a dignified way to describe a person, and this was not identified by the registered manager or senior staff. Staff and leaders did not demonstrate a positive, compassionate, listening culture that promoted trust and understanding between them and people using the service. There was not a culture within the service that focused on learning and improvement. Staff and the registered manager did not have a well-developed understanding of equality, diversity, and human rights, and they did not prioritise safe, high-quality, compassionate care.

Systems and processes were not effective to ensure that there was a positive culture within the service. During our assessment, we identified a closed culture; a closed culture is a poor culture in a health or care service that increases the risk of harm. This includes abuse and human rights breaches. People's rights were not being upheld because they were not included in decisions about their life and the support they received, and some people had been subject to unlawful physical intervention. We found that the information supplied to us by the registered manager was not always correct, and in one case an incident report had been deleted by the registered manager.

The registered manager told us incorrect information relating to people and was not always open and honest with us. For example, in relation to the people they were supporting, the registered manager did not tell us of two further people who accessed people's homes as part of a respite service.

The registered manager, and senior staff within the service did not have the skills, knowledge, and experience to perform their role or have a clear understanding of people’s needs/ oversight of the services they managed. The registered manager and senior staff did not understand and demonstrate compliance with regulatory and legislative requirements. We identified that notifications were not submitted to CQC, or safeguarding concerns to the local authority safeguarding team. The registered manager and senior staff were not alert to any examples of poor culture that may affect the quality of people’s care and have a detrimental impact on staff. This had not been identified or addressed quickly.

Staff told us they were assured that if concerns were raised internally the registered manager would take appropriate action. However, we identified several instances where this had not occurred. Following our assessment, we contacted the local authority safeguarding team to inform them of incidents that had not been reported to them.

Although staff and the registered manager told us they understood their responsibilities to raise concerns, we found this was not always done. Staff had completed training in safeguarding and told us they felt confident to raise concerns internally and externally. Systems to ensure that staff and the registered manager understood and carried out their duties to raise concerns internally and externally were ineffective. The registered manager did not always conduct themselves in an open and honest way. They told us incorrect information about the people they supported on numerous occasions. They had not been open with the local authority safeguarding team.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Although staff and the registered manager told us they understood their responsibilities we found that these were not always carried out. For example, although staff documented incidents, the registered manager did not always review them, and implement improvements. Staff failed to report the use of physical intervention in line with safeguarding processes, and the registered manager did not identify or report these. Services that provide health and social care to people are required to inform the CQC, of important events that happen in the service. This enables us to check that appropriate action had been taken. Following our assessment, we reported 15 incidents of abuse to the local authority safeguarding team.

Oversight of the service was poor and ineffective. The registered manager, and management team completed audits on the quality of the service, however these were ineffective as they failed to identify the widespread and serious concerns highlighted within this assessment. There was a lack of oversight in relation to review of care plans and risk assessments to ensure they provided key guidance for staff to follow. Care plans and risk assessments were poor, and people received inconsistent support in relation to their epilepsy, or incidents of distress. The registered manager missed the opportunity to identify and improve the service through robust governance. Governance processes were poor and did not keep people safe, protect people’s rights or provide good quality care and support.

While the people we spoke to expressed that they were generally happy with their care, our assessment found care did not meet the expected standards. People had trusted the provider and registered manager to share important information about their care with partners, to ensure learning and improvements which would lead to better outcomes for people. This had not happened. Because of this, people’s rights had not been upheld and, in some cases, people had been harmed. For example, there were multiple occasions when one person spat at another, and multiple instances when one person targeted another person. The registered manager told us they did not report incidents of abuse, because they knew the person did not intend to cause the other person harm. The registered manager failed to consider how this would impact on the person experiencing abuse.

While staff we spoke with, including the registered manager told us they worked well with key partners, we identified this did not always occur. Staff and the registered manager did not work with partners in a collaborative way to share concerns about the risks to people or incidents that had occurred. People were placed at significant risk because the registered manager failed to be open and transparent with partners about significant incidents which happened between people where harm had occurred. The registered manager had failed to be open and honest with us and with key partners, or to share key information about the service people received, and important information about people’s safety. The failure to work collaboratively with partners had a detrimental impact on people’s safety and outcomes.

Social care professional partners have worked alongside CQC during this assessment. They are reviewing current care packages due to concerns about people’s safety. Partners told us they had not been informed of serious safety concerns regarding the people they commissioned, and they had been concerned to learn of incidents of restraint and unsafe practices.

There were inadequate processes in place to ensure seamless partnership working. The provider and registered manager had not been open or transparent with partners about people being harmed, unlawful restraint, or that other people were receiving a day service in people’s homes. The registered manager had failed to establish robust processes for sharing information with partners when significant events had occurred and people had been harmed. Some people had been significantly harmed both physically and psychologically but the registered manager had not shared these concerns with partners. The absence of effective processes meant that people were not involved in their care, and partners were not involved in meaningful engagement with the provider to explore learning and improvement.

Staff and leaders did not have a good understanding of how to make improvements happen. Their approach was not consistent and did not consider including measuring outcomes and impact for people. Staff and the registered manager had not effectively reviewed people’s care and support on an ongoing basis and did not recognise that people’s needs and wishes could change over time. Staff were not always supported to prioritise time to develop their skills around improvement and innovation. There was not a clear strategy for how to develop these capabilities and staff are consistently encouraged to contribute to improvement initiatives. The registered manager had not identified that the principles of PBS or RSRCRC were not embedded into the service, or the care provided.

There were not effective processes to ensure that learning happened when things went wrong, and from examples of good practice. There was a lack of oversight of accidents and incidents and the registered manager could not demonstrate how lessons were learnt when things went wrong. There were no examples of care plans and risk assessments being updated, new training implemented for staff following incidents, or learning from external safety alerts. The registered manager could not demonstrate that they kept up to date with national policy to inform improvements to the service.