Gillingham Road

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

At our last inspection we rated this key question good. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in people’s care, support and outcomes. The service was in breach of legal regulations in relation to people and their relatives were not always involved in assessments around their care, meaning their contributions could be missed. People’s rights were not always protected due to the principles of the Mental Capacity Act (MCA) not being applied appropriately. People received varied experiences in accessing specialists to meet their health needs. People were not receiving person centred, evidence-based care, specific to their needs.

This service scored 25 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People’s wellbeing was not always being considered when reviews of care were undertaken by the provider/registered manager. Relatives told us they were not always involved in the review of their loved one’s care. One relative said, “Me and [person] can’t access the care plan.” A person’s transition plan to moving to another service was poorly managed. The service had not involved the family in the person’s proposed move to one of their supported living services to ensure it met their needs. Whilst we saw other reviews of care had taken place by the provider/registered manager there was very little detail on how people had been involved with this.

People did not always receive support that was in line with good practice standards to ensure compassionate and therapeutic care and support. The provider/registered manager told us they had not sought input from professionals to support the guidance in the ‘Behaviour Support Plans’ [PBS] for people. We saw 1 person’s PBS was a copy and paste from the persons previous home where they lived with other people. This had not been updated to reflect their new living environment. Where people were at risk of malnutrition, the provider/registered manager completed a Malnutrition Universal Screening Tool (MUST). However, these were not completed accurately and did not reflect the person’s current weight. On 1 MUST it recorded the person was at high risk of losing weight however it was then scored as low risk. This left people at significant risk of harm.

We found the provider/registered manager and staff were not always providing the professionals with accurate feedback on people’s care. We found they were not requesting guidance and advice around people’s PBS or mental health needs. Stakeholders told us they had concerns with the lack of communication from the provider/registered manager. There was a heavy reliance from staff on the provider/registered manager to update health care professionals where support was needed for people. When we asked staff how they supported people with their health needs, they told us they would refer to their manager. We found 1 person was being supported by staff to undertake an intrusive procedure to assist them with their continence. However, there was nothing in the person’s care plan to state whether an external professional had been consulted in relation to this. This placed the person at risk of harm.

There was a lack of information in people’s care plans on how they were supported with their health care including how they accessed the dentist, optician and GP. We saw from 1 person’s care notes, they had a health review in 2023, and it was recommended they were supported to eat more healthy foods. There was no update to this or whether a further health review had been arranged for them or whether this health issue still remained. Another person had been registered to the GP however the provider/registered manager had not taken sufficient steps to arrange a health review for them in their home. The failure to ensure people received appropriate health care support left people at significant risk of harm to their health and their wellbeing.

People’s health and wellbeing were not being reviewed relating to people’s quality of life. The provider/registered manager told us all people were allocated a key worker. [A key worker makes sure that all staff involved are working together, and that the care plan is being followed and is helping. They ensure that any assessments, care and treatments are explained clearly to the person with a learning disability.] The provider/registered manager told us the keyworkers would have a meeting each month with the person they were supporting. However, when we asked for evidence of these meetings, they told us these were not recorded. People we spoke with were not aware of any meetings with key workers.

Leaders and staff did not act in accordance with the requirements of the Mental Capacity Act (MCA) 2005 and associated code of practice, or their own MCA policy. Where people lacked capacity to make complex decisions, the provider/registered manager had not undertaken decision specific capacity assessments. For example, we were told 1 person lacked capacity, yet the provider/registered manager told us they were independent with their medicines. The provider/registered manager had not undertaken a capacity assessment in relation to this. The provider/registered manager had also asked the person to sign their care contract, yet they had not determined the person’s capacity to do this. Where decisions were being made for people, there was not always evidence their capacity had been appropriately assessed. This particularly related to people where the provider/registered manager had restricted when they could have visitors in their own homes and telling us they were going to install CCTV in a person’s home without considering the person’s capacity to consent to this. There were no assessments of the person's capacity to agree to this restriction to determine whether this was in the person's best interests' or whether less restrictive measures had been considered.