Updated 12 September 2025
Date of inspection 22 September 2025 to 23 October 2025. The service is a care home for 20 people providing care and support to people with a learning disability and/or autistic people. At the time of this inspection, 20 people were living at the service.
The inspection was carried out in response to the outcome of a coroner case where recommendations were made. We found 3 breaches of regulations relating to safe care and treatment, consent and governance.
We 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 found the service was not always supporting people with a learning disability in line with this statutory guidance.
Risks to people were not always identified and mitigated, including environmental and infection control risks. Safe medicine practices were not always promoted. The service was not working to the principles of the Mental Capacity Act 2005 which failed to safeguard people.
Records were contradictory and terminology used was not always in line with best practice. Governance systems were not effective in identifying all areas for improvement.
People were safeguarded from abuse and had access to a range of health professionals to promote their health and well-being. They were supported to be involved in a wide range of person-centered activities, including community activities.
Staff were suitably recruited and supervised. They had access to a range of training; however, staff did not have their competencies assessed for all aspects of tasks they were involved in.
The provider and manager were proactive in response to our feedback, and they took immediate actions to address the findings, to safeguard people.
We have asked the provider for an action plan in response to the findings and to enable us to monitor progress within the service.