Updated 6 February 2026
We started this assessment on 24 February 2026, when we attended the office. We visited people in their homes on 5 March 2026, 11 March 2026, 12 March 2026 and 19 March 2026.
We reviewed documents and information, spoke with relatives and staff and had follow up contact with the provider, finishing the assessment on 7 April 2026.
This was a responsive assessment, following an assessment that took place in July and August 2025 when the service was placed in special measures and received four warning notices for breaches in regulations. In between the last assessment in July and August 2025, and this one, we continued to receive a high level of concerns in relation to the provider, from staff and stakeholders.
We assessed the service against our ‘Right care, right culture, right support’ 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 found the provider was not supporting people in line with this guidance.
The provider runs a supported living service and provides the regulated activity of personal care to some people using the service, so we only viewed information relating to people receiving a regulated activity, which was 13 people at the time of the assessment.
People’s needs were not effectively assessed, and risk was not effectively managed. Staff had not received all the appropriate training to support people effectively; care plans and risk assessments did not contain enough detail for staff to safely mitigate risks such as risk of falls and epilepsy.
We found that staff recently recruited to the service, had not been properly and safely vetted prior to their employment. This included the recently appointed manager’s employment process, as managers and leaders of the provider did not understand how to use the DBS online update system. At the time of our assessment, the manager had not yet registered with us but was at the application stage of the process.
We found that some staff were working excessive hours with little or no breaks in between. For example, we saw that one staff member had worked a 31-hour shift, which included a waking night. This was raised with the managers; however, we did not see sufficient action taken to address this concern as we viewed rotas for upcoming months (April 2026 and the start of May 2026) and found that the provider continued to schedule staff in for shifts of 24 hours and more with no rest.
The oversight of the service was poor, since our last assessment, governance systems had been implemented, such as regular audits, however, these were not completed to a good standard nor did they provide relevant prompts within them, which would lead managers to look at certain aspects of the service. We found that where managers found issues in the service through audits, these were not always escalated and addressed.
We found that conflicts of interest between employees were still not effectively managed and there was no system or process in place to mitigate potential conflicts. This had been raised at our previous assessment in 2025. We were told by managers on day 1 of this assessment that as a rule, staff with personal relationships do not work together, however, when reviewing rotas, this was not the case. This had been addressed by the end of our assessment.
We found that the provider had not addressed many of the concerns raised in the warning notices we issued in September 2025, and in the report, we published in November 2025, which meant people were still at risk. For example, we had raised concerns around epilepsy management, and asthma management, however these concerns were still present at this assessment meaning that people continued to be at risk of harm.
We found the provider was in breach of five legal regulations. These related to consent, safe care and treatment, good governance, staffing and fit and proper persons employed. We were not assured by the end of our assessment that the provider or managers were equipped to make the necessary changes to rectify our concerns. The provider employed a new manager who had not been in their post for long prior to our assessment.
The service continues to be rated inadequate. This service remains in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provides a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of care they provide .
In instances where CQC have decided to take civic or criminal enforcement action against a provider, we will publish this information on our website after any representations and/or appeals have been concluded.