Updated 25 November 2025
We completed assessment visits to Keys Hill Park on 10,12, 17 and 24 September 2025. This is a service for people with a learning disability, autistic people, people with mental health needs and/or physical disabilities. 27 people were living at the service at the time of our assessment.
People were supported within a mix of shared houses and single accommodation within Keys Hill Park. The service was developed on one site which does not fully meet best practice guidance. We were not fully assured the provider had mitigated the risks of people being isolated from their local community.
Recruitment of new staff had been a significant challenge for the service and meant people did not always receive support from staff who were familiar with their needs. This increased the risk of people receiving unsafe care. Where people did have regular teams of skilled staff, this was working effectively. However, this meant the quality of life some people experienced was impacted by inconsistent staffing.
Not all staff had received training in line with the needs of the service, although staff told us access to training had significantly improved over the last year.
Staff reported working long hours and experiencing fatigue and told us they did not always feel well supported by the management team or the registered provider. They described pressures were magnified by the high use of agency staff, new starters, staff vacancies and new admissions. This meant we were not assured people always received good person-centred care from staff who knew them well.
The provider had introduced a new electronic record system, with the capacity to improve records about people. However, agency staff did not have access to this record system and relied on paper records which often lacked up to date information about people’s needs. Furthermore, electronic records were not always updated in a timely way. This meant audits were not always effective and the governance and oversight in place was poor.
We identified unmanaged risks associated with fire, epilepsy, and a lack of guidance for staff about how to recognise and safely support people when distressed. These were addressed by the provider following us raising immediate concerns with them.
The last rating for this service was good (report published 11 June 2019). We carried out this assessment due to the length of time since we last inspected. We looked at all the quality statements and the overall rating for this service has changed to requires improvement.
We found the service was in breach of 4 regulations of the Health and Social Care Act (2014) in relation to safe care and treatment, safeguarding, staffing and good governance.
We have 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 identified improvements were needed in terms of consistency, continuity and promoting positive choices against risks. We found the provider was not always meeting the principles of Right support, right care, right culture. These issues affected the safety and quality of care provided.
In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/ or appeals have been concluded.