A company providing supported living has been placed in special measures after a number of service users “came to actual harm” while in its care.

The Care Quality Commission (CQC) has taken action to protect people using HF Trust Limited in Kent after surprise inspections found “the most basic” of people’s needs were not being met.

Inspectors visited the Kent branch of the national company – which previously had a rating of ‘good’ – after being informed of a number of concerns over safety and leadership.

The service provides support to people with a learning disability and/or autism staying in supported living settings in ‘clusters’.

At the time of the inspection it was providing support to 69 people based out of sites in Edenbridge, Lympne, Hythe and Folkestone.

Inspectors visited four settings, speaking to 10 service users and five relatives about the care. They also spoke to 17 members of staff including the registered manager and managers of individual clusters.

When they did, they found a number of concerning failings, several of which resulted in service users being harmed unnecessarily.

In one such incident, inspectors heard that a patient with epilepsy suffered a fit lasting 15 minutes, during which time staff neither gave them the rescue medication that they needed nor alerted the management to the incident.

They also heard that choking risks were not properly managed, with inspectors seeing a member of staff give a hard chocolate sweet to a person who was only supposed to be given pureed food due to a suspected choking risk.

Similar incidents involving choking and seizures often went unreported, it was found, with a number of incidents noted but not entered into official records – one manager told inspectors that they were aware that a service user had experienced more seizures than were documented on their seizure chart.

The damning report also revealed that a service user fell down the stairs during a fire alarm evacuation, after members of staff failed to follow their personal emergency evacuation protocol that stated they needed the assistance of an electric chair to get down the stairs.

Additionally, some medicines were given too frequently – with one user given a medication twice a day for 25 days without any reason, despite the fact that it should have been given “only when needed”.

Meanwhile, another service user’s issues with constipation were so poorly managed that they required hospitalisation for treatment.

The myriad issues found by inspectors in May and June resulted in the company’s ‘good’ overall rating – achieved in 2018 – being downgraded to inadequate.

Included within this, the rating for how safe and well-led the service is was also dropped from good to inadequate, while the rating for how effective the service is was dropped from good to requires improvement.

Inspectors did not examine how caring and responsive the service is, so that category remains rated at good.

Rebecca Bauers, CQC’s director for people with a learning disability and autistic people, said: “Our experience tells us that when a service isn’t well-led, it’s more likely they’re unable to meet people’s needs in other areas we inspect, which is what we found at HF Trust Limited - Kent DCA.

“Our priority remains ensuring the best outcomes for the people we support...”

“Leaders weren’t managing this service well, and standards of care had deteriorated significantly since our previous inspection. A lack of cohesive, effective leadership resulted in people being put at serious risk of avoidable harm and abuse.

“It’s unacceptable that the most basic of people’s needs weren’t being met, which sometimes resulted in them coming to actual harm, particularly around medications.

“There were not enough skilled and competent staff on duty to keep people safe, this must be addressed as a priority.

“However, feedback we received from relatives at the inspection was generally positive about the care staff provided and the registered manager was receptive to our concerns during the inspection and took some action to address them.

“We’ll continue to monitor the service to ensure all the necessary improvements are made. We’ll return to check they’ve made the required improvements, if we are still not assured people are receiving safe care, we’ll not hesitate to take further action.”

Kirsty Matthews, HFT CEO, says the company has acknowledged the report and warning notice for the service.

“We deeply regret that the service has not met the high-quality standards we set for ourselves as a care provider,” she added.

“The management team and our central quality colleagues are working through a detailed action plan to ensure the issues highlighted in the inspection are rectified at pace and with the highest quality and governance.

“Our priority remains ensuring the best outcomes for the people we support at the service and we will continue to work closely with the CQC to take the steps needed to improve the quality of care at the service.”