27 June 2023
During an inspection looking at part of the service
People’s experience of using this service and what we found;
We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.
Right Support:
Care was not always provided in a dignified manner which had the potential to compromise people’s human rights. Staff were trained in restrictive practices, and we found people's records mostly, not all, had guidance in place for staff to follow when using control and restraint. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
Right Care:
Care was not always provided in a person-centred way which promoted people's dignity, independence or human rights. There were not always staff with suitable skills deployed to meet the needs of people. There were some gaps in staff training, and we were not assured staff had the skills and knowledge to fill the requirements of their role. Medicines were not always safely managed, and medicine records were not always completed accurately.
Right Culture:
The service lacked effective oversight and leadership. The provider's systems for monitoring and improving the quality of the service had not been effective. Learning from events was not always shared with the staff team. This placed people at potential risk of harm.
The failings outlined in this report demonstrated the provider had failed to ensure people received a well-managed service which was safe and compassionate placing people at risk of potential harm.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was good (published 14 July 2021).
Why we inspected
The inspection was prompted in part by notification of an incident following an allegation of abuse. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of the incident. However, the information shared with CQC about the incident indicated potential concerns about the safeguarding procedures and the culture within the service. This inspection examined those risks.
As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.
The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for An Darach Care - Cambridgeshire on our website at www.cqc.org.uk.
Enforcement
We have identified breaches in relation to safe care and treatment and good governance at this inspection. Please see the action we have told the provider to take at the end of this report.
Follow up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.