During an assessment under our new approach
We started the assessment on 25 July 2025, visiting the office and people using the service in their homes, as well as 05 August 2025. We visited people using the service in their homes on 30 July and 08 August 2025. We reviewed documents and had follow up contact with the provider, finishing the assessment on 02 September 2025.
This was a responsive assessment in response to an increase in concerns being raised through ‘give feedback on care’ and information sharing from stakeholders.
The provider runs a supported living service, which means 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. At the time of our assessment the provider had not ensured that their registration reflected the service being delivered as their registration was as a domiciliary care service not supported living.
The service 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. At the beginning of our assessment, we were informed there were 6 people receiving a regulated activity, however through the duration of our assessment, we found there were more that had not been shared with us, and in total there were 13 people in receipt of a personal care.
People’s needs were not effectively assessed, and risks were not effectively managed. Staff had not received all the appropriate training to safely support people with specific needs, and there was not enough detail and evidence of effective risk management, including where people were at risk of falls, or had health conditions, such as epilepsy.
Staff were not recruited safely, and there was a poor procedure in place for recruiting staff and supporting them through a probationary period before beginning their roles. We found that staff were not allocated, or required to complete any training, including safeguarding training, until they had been in their role for 12 weeks. At this point, they were already providing support to vulnerable adults in the care of the provider. There was no reliable system in place to assess whether new staff were competent to complete their role, that could mitigate the need for training in the first 12 weeks of their employment.
Staff received regular supervision, but there was mixed feedback on the support staff received, and how meaningful supervisions were. Some staff told us that they were treated unfairly by managers, one staff member told us in relation to staff morale, “it is the lowest I’ve ever experienced” and “there is a clear culture of favouritism”. Another staff member told us, in relation to supervisions, “it helps me feel supported and professionally developed”.
The oversight of the service was poor; there were no manager or provider audits being completed. There were two weekly audits completed by Team Leaders, in relation to medication and financial balances. These audits were not in depth, and therefore failed to identify issues, such as expired medications, which we found during our assessment.
We provided feedback throughout the duration of our assessment to managers and the provider, and managers were quick to take action to rectify individual issues, but we were not assured that the actions taken had been done with full understanding and consideration of the situation, and at points, led to other concerns, such as people being left at higher risk.
We were not assured that the provider was transparent with us during our assessment, in relation to the amount of people receiving personal care from the provider, or in relation to conflicts of interest, where people employed by the service have personal relationships with one another. We were given assurances throughout our assessment, that new staff members who we found had not been recruited safely, nor received any training, were not lone working and at that stage, were only shadowing experienced members of staff. We found this was not the case.
The provider was found to be in breach of five legal regulations. This related to consent, safe care and treatment, safeguarding, good governance and fit and proper persons employed by the provider. 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, however, we were informed an additional manager would be taken on to support with this process, who has recent experience of improving a different service.
The service has been rated inadequate. The service is being placed 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.