CQC takes action to protect residents at Threeways Dom Care

Regulator, the Care Quality Commission (CQC), has taken action to protect people living at Threeways Dom Care in Redhill, Surrey, after serious failings led to the announcement of the unit’s closure, with vulnerable residents given less than a month to find alternative provision.

The service has also been rated as ‘inadequate’ and placed in special measures, following an inspection in July, which found that staff were not trained in epilepsy management and ignored ‘basic health and safety practices’, records were not up to date, and residents ‘lacked meaningful engagement’, putting them at ‘serious risk of harm’ and ‘exposing them to avoidable risks’.

Threeways Dom Care is a supported living service providing personal care for up to three adults with a learning disability.

At the time of the assessment, two people were using the service.

The CQC assessed the service using its right support, right care, right culture guidance.

This gauges whether a service guarantees autistic people and people with a learning disability the respect, equality, dignity, choice, independence, and access to local communities that most people take for granted.

At the inspection CQC found six breaches of the legal regulations relating to person-centred care, safe care and treatment, mental capacity, safeguarding, staffing, and how the service was managed.

The day after the inspection the owner told people the service was closing and gave everyone there 28 days notice to find alternative care.

Following the inspection, the service’s overall rating and the areas of safe effective, responsive, and well-led have all been rated as ‘inadequate’. 

Caring was also rated as ‘requires improvement’.

The 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.

In addition, the CQC has begun the process of taking regulatory action to address the concerns, which Threeways Dom Care has the right to appeal.

Roger James, CQC’s deputy director for Surrey, said: “Our inspection of Threeways Dom Care exposed serious leadership failings that was denying people dignity, respect, and independence in their care.

“The day after our inspection the owner told people the service was closing and gave everyone 28 days notice. By doing so, Threeways ignored people’s voices, failed to inform them or their relatives of their rights as tenants, and put an enormous amount of unnecessary stress on people as well as making the transfer to a new care service for them more difficult.

“Staff didn’t consistently involve people or their loved in care planning. They also didn’t take account of people’s life histories, which meant care lacked personalisation and sensitivity.

“People weren’t supported to make informed choices, and opportunities to build independence were missed.

“We found the service didn’t always support people’s basic health needs. Staff failed to encourage nutritious diets, and records of behaviours and triggers were incomplete, preventing patterns of risk being recognised to improve people’s support.

“Leaders also failed to make sure staffing was safe, or that agency staff had the right skills and training to meet people’s needs. Some staff also treated people unkindly.

“The service didn’t promote an open and honest culture. Concerns and safeguarding incidents weren’t always identified or escalated, meaning risks to people’s safety went unchecked. This left people vulnerable to harm and without the protection of external partners.

“At the time we saw people’s experiences of transitioning to other services was poorly managed. Without clear or personalised plans, moves became disjointed, leaving people anxious and unprepared.

“We weren’t assured leaders understood the impact this had on people’s wellbeing.

“We have told leaders where we expect to see rapid, and continued improvements and will continue to monitor the home closely to keep people safe while that happens. 

Inspectors found:

• Staff didn’t ensure records were accurate or up-to-date care, leaving people at serious risk of harm
• Leaders didn’t ensure staff received training in epilepsy management, exposing people to avoidable risks
• Staff wore unsafe footwear and ignored basic health and safety practices in the environment
• People told CQC that they lacked meaningful engagement, reducing opportunities for them make choices
• Leaders failed to ensure staff had the guidance and training to meet residents’ individual health and safety needs