HF Trust - Kent DCA was rated Inadequate overall following a focused inspection across safe, effective, and well-led domains, with multiple regulatory breaches identified including unsafe medicines management, failure to follow Mental Capacity Act principles, and significant governance failures. The service was placed in special measures due to widespread risks to people with a learning disability and/or autism across its 12 supported living clusters in Kent.
Concerns (12)
criticalMedication management: “A person who had epilepsy was not given their emergency medicine in line with their protocol. The seizure had not been recorded in the person seizure records.”
critical
Safeguarding
: “Not all incidents had been identified and reported to the local authority safeguarding team.”
criticalIncident learning: “Choking incidents had not been reported. A person was documented within the communication book as having choked, however there was no incident form.”
criticalGovernance: “Audits and spot checks that should have been completed by the registered manager and the management team had not been.”
criticalStaffing levels: “Staff who worked at one of the clusters had not been trained to administer emergency epilepsy medicine where there was an identified need.”
criticalConsent / capacity: “People with sensors or monitors in their bedrooms did not have capacity assessments or best interest decisions.”
criticalStaff competency: “An agency staff member we spoke with was unaware of rescue medicines people within their cluster needed.”
moderateCare planning: “The care plans need reviewing, people's needs have changed since they were put in. They are not great, not easy to follow.”
moderatePerson-centred care: “A person's documentation stated they 'must be sent to their room as they can upset other residents and staff.'”
moderateRecord keeping: “Some liquid medicines and creams did not have an open date on the bottles to ensure the medicines were discarded after a certain time period.”
moderateLeadership: “Only 35% of staff said they would recommend HF Trust - Kent DCA as a great place to work.”
minorCommunication with families: “People were not involved in care planning or setting goals or aspirations.”
Strengths
· Staff had received training in safeguarding and most had up-to-date knowledge of how to recognise and report abuse.
· People were supported to maintain a balanced diet, with some clusters involving people in meal planning and preparation.
· Infection control was well managed, with sufficient PPE available and people supported to access vaccinations.
· Safe recruitment processes were in place, including Disclosure and Barring Service checks before new staff started.
· Staff and the registered manager worked in partnership with other professionals such as the mental health team, occupational therapist and GP.
Quality-Statement breakdown (16)
safe: Assessing risk, safety monitoring and managementInadequate
safe: Learning lessons when things go wrongInadequate
safe: Using medicines safelyInadequate
safe: Staffing and recruitmentRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseRequires improvement
safe: Preventing and controlling infectionGood
effective: Ensuring consent to care and treatment in line with law and guidanceInadequate
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Staff working with other agencies to provide consistent, effective, timely careRequires improvement
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawRequires improvement
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
well-led: Managers and staff being clear about their roles, understanding quality performance, risks and regulatory requirementsInadequate
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringInadequate
well-led: Engaging and involving people using the service, the public and staffRequires improvement
well-led: Working in partnership with othersGood
well-led: How the provider understands and acts on the duty of candourGood
Date of assessment: 25 November 2024 to 23 January 2025. HF Trust Kent DCA is a supported living service registered to provide personal care to people with a learning disability and or autism. We undertook the assessment as the provider had been in Special Measures since 27 July 2023 with breaches of regulation. We needed to check whether these had been met. Improvements had been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures. The service had made improvements and was no longer in breach of regulations in relation to the safe care and treatment or need for consent. Shortfalls were found at this assessment, and the provider remained in breach of regulation in relation to the governance systems. Checks and audits were not always robust to identify and take action on all shortfalls. Staff felt on occasions their views were not always listened to or acted on. People told us they enjoyed living in their houses. People were at the centre of their care and made decisions about their lives. Staff were kind, treated people as individuals, empowered them to maintain and develop independent living skills and relationships. Staff protected people’s privacy and dignity and responded in a timely way. People were kept safe from potential abuse. Potential risks to people were assessed and mitigated however, staff did not always follow guidance to ensure people’s safety. Staffing levels had improved, people received their commissioned hours of support and continuity of care. We assessed the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence and good access to local communities that most people take for granted. We have asked for an action plan in response to the concerns found.
PDF cached but not yet analysed by Claude; set ANTHROPIC_API_KEY and re-run npm run etl:reports -- --location 1-693225980.