CQC Places Coventry Care Service in Special Measures Following Significant Risk Management Failures

Following its latest inspection the Care Quality Commission (CQC) has placed RNIB Pears Centre for Specialist Learning; 5 Pears Court into special measures and rated it as Inadequate overall.

The children’s home at Five Pears Court is one of a group of specialist built bungalows at the Pears Centre in Ash Green, Coventry. The centre provides care for children and young people up to the age of nineteen and there is a school and accommodation for children attending the school on the same site, which is regulated by Ofsted.

The CQC carried out this inspection - following concerns raised by Ofsted about the part of the facility it regulates.

At the time of CQC’s first two visits during this inspection four children or young people lived at 5 Pears Court, but by the time of the second visit, on 5 April, one child had been removed from the service by commissioners, due to concerns surrounding their care and welfare.

Key Concerns:

• The Provider’s Information Return (PIR) did not reflect the findings of the inspection.
• The CQC found safeguarding concerns were not always recognised by staff and managers when incidents occurred at Bungalow 5. 
• Staff and managers had not received the appropriate level of safeguarding training to meet the needs of children and young people at the home. 
• Risks to people's health and wellbeing were not always identified, and risk management plans were not always in place to instruct staff on how they should manage risks to people consistently and safely. 
• There were not always sufficient qualified and trained staff on duty to care for children and young people safely, and to meet their social needs. 
• There was a lack of leadership for staff at the home, including clinical leadership. 
• The CQC found there was no current analysis and overview of accidents, incidents, complaints, feedback and safeguarding concerns at the home to assess whether any trends or patterns were identified and future risks could be mitigated. 
• The registered manager and provider did not fully understand their responsibility to comply with the requirements of the Mental Capacity Act 2005 (MCA) and work within the principles of this. 
• Children and young people were not always supported in a way that respected their privacy and dignity. 
• Children and young people were not always offered activities and social experiences that met their requirements and social needs. 
• Quality monitoring procedures needed improvement to ensure these were undertaken regularly, to monitor service provision. 

Maggie Hannelly, CQC’s Head of Inspection for Adult Social Care in the central region said “Inspectors found the service was failing to provide safe care. Risks to people’s health and wellbeing were not always identified, and risk management plans were not always available to instruct staff on how they should manage risks to people consistently and safely.

“There were not always sufficient qualified and trained staff on duty to care for children and young people safely and we were concerned about a lack of strong leadership at the service. As a result of our findings, the service has been rated Inadequate and placed into special measures.

“The service must ensure it takes robust action to ensure improvements are made and we will return to carry out further inspections.”