Understaffing, failure of leadership and poorly maintained accommodation were among reasons inspectors placed a learning disability service near Lincoln into special measures.
The Care Quality Commission (CQC) conducted an unannounced inspection at Healthlinc House, run by Elysium Healthcare, in Welton in April.
The service cares for people with a learning disability and autistic people. It had 22 residents at the time of inspection, including some detained under the Mental Health Act.
Inspectors, in a report published on Wednesday, July 21, rated the service ‘inadequate’ overall and placed it in special measures after they found a shortage of suitable staff to deliver good quality care and ensure people’s wellbeing.
While the families and carers of people at the facility felt that they were happy, and staff were kind, helpful and friendly, the CQC said the provider relied heavily on temporary agency staff who did not know the people they were caring for.
The provider did not check qualifications or ensure all had training, did not handle distress effectively, resulting in injury to staff and others, and the lack of cover meant staff weren’t able to take breaks.
Accommodation at Healthlinc House was described as tired with sparse and dated furnishings, some windows were broken and some areas were not clean.
Inspectors also told providers they needed to address delays in discharges in order to prevent clients from becoming institutionalised.
There were eight delayed discharges. The longest length of stay was nine and a half years, and the other seven delayed discharges ranged from six to three years.
However, staff understood how to protect people from abuse and risk assessment and support plans were of high quality.
All carers spoken to said they felt their loved ones were happy and staff were kind.
It was previously rated ‘good’ overall following an inspection in 2019.
Debbie Ivanova, CQC deputy chief inspector for people with a learning disability and autistic people, said: “It was concerning that staff did not always know how to prevent people from becoming distressed, and they were not always able to support them when this happened. People using the service deserved better.
“It was unacceptable that poor discharge management meant some people spent years at the service when their needs may have been better served elsewhere.
“We also found the physical environment was poorly maintained. It was unclean and worn-out in places, undermining the care people received.
“Behind these issues was a failure of leadership. Leaders did not have oversight of the service to identify problems or articulate a vision for how it should improve.
“We are monitoring the service closely and will take further action to protect people if they are at immediate risk of harm, or if the service does not evidence how it will meet its obligations to its patients.”
A spokesperson from Healthlinc House said the company has introduced an improvement plans since the inspection: “The safety and wellbeing of our residents is our highest priority, and we are grateful to our partners at the Care Quality Commission (CQC) for their scrutiny when they visited back in April 2021.
“The results of the inspection were disappointing, but we immediately implemented a significant quality improvement plan. As it has now been over three months since the inspection, the improvements we have made are well embedded.
“We look forward to evidencing the improvements to the inspection team on their upcoming visit.”