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Salcasa Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 11 September 2021

About the service

Salcasa is a residential care home providing care and support to people with a learning disability and/or autistic people. The service can support up to five people. At the time of the inspection there were five people living in the home. Salcasa is a single storey building with a large garden and an attached annexe.

People’s experience of using this service and what we found

Quality monitoring systems and governance in the service was not effective. There was a lack of clear guidance for staff on how systems should be used. Support plans were not always accurate or up to date. There was a lack of recorded information relating to risks that affected people. This had reduced the ability of the management team to assess and monitor risks. Where such information had been recorded no formal audits or oversight was in place to help monitor and assess potential risks. The electronic care record system was not being consistently used as it did not always work or did not meet the needs of the service. This meant staff were duplicating information and there was a risk information could get missed due to two systems operating.

Not all risks relating to people and the environment had been assessed or responded to robustly. However, the impact from this was minimal due to the support provided by the stable, consistent and knowledgeable staff team. Principles of healthy eating and support around this were not embedded in the service. The management team confirmed this was an area they were continuing to work on and had recently introduced some new measures around this. Some historic safeguarding incidents relating to 2019 had not been reported to CQC or the local authority. We were confident from speaking with the registered manager that this was a historic concern and similar incidents would be reported if they had occurred more recently. Recruitment checks were in place which included assurances of good character, however gaps in employment history had not always been fully explored.

People were supported by staff who knew them well and had a good understanding of their individual needs and risks, including how to monitor and mitigate them. Medicines were managed safely, and people received their medicines as prescribed. There was enough staff to meet people’s needs. People were protected from the risk of infection and were living in a clean sanitary environment. Incidents that occurred in the service were reviewed and staff were supported to learn from these.

There was a person-centred ethos in the service and people were supported to achieve good outcomes. People were supported by a positive cohesive staff team who worked well together. Relatives were happy with the support provided and the communication from the service regarding this.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right Support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

Based on our review of safe and well-led the service was able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture. Systems were in place to help support people to be involved in their care and support. The care delivered met people’s individual needs. During our conversations with staff and the management team they demonstrated a person centred and inclusive ethos.

For more details, please see the full report which is on the CQC website at

Rating at last inspection

The last rating for this service was good (published 19 February 2019).

Why we inspected

This was a focused inspection to check on a specific concern we had about the provider’s governance systems and oversight of the service.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvement. Please see the well-led and safe sections of this report.

You can see what action we have asked the provider to take at the end of this report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Salcasa on our website at


We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to good governance at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Inspection areas


Requires improvement

Updated 11 September 2021

The service was not always safe.

Details are in our safe findings below.



Updated 11 September 2021



Updated 11 September 2021



Updated 11 September 2021


Requires improvement

Updated 11 September 2021

The service was not always well-led.

Details are in our well-Led findings below.