Updated 21 November 2025
We carried out this assessment from 12 December to 15 December 2025. Bells Piece - Care Home Learning Disabilities (Bells Piece) is a residential service providing support for up to 13 adults with a learning disability and autistic people. At the time of our assessment, 11 people were using the service.
We undertook this assessment due to concerns regarding the management oversight of the service. During our assessment, we found 3 breaches of regulations in relation to safe care and treatment, person-centred care and good 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 that the manager and staff team were unaware of this guidance, and that people did not always receive care and support in accordance with its principles. As people’s needs, preferences, aspirations and outcomes were not reviewed in line with the guidance, they were not supported to have as ordinary a life as possible.
The home was not always cleaned to an acceptable standard, and some areas required refurbishment. People were supported with their medicines in line with prescription guidelines, although systems to ensure medicines were stored safely were not always followed. Staff were aware of risks to people’s safety and well-being and took steps to keep them safe. However, records regarding guidance and risk management were not always current and on occasion contained contradictory information.
Systems to review the quality of the service were not always effective as concerns were not identified, such as the cleanliness of the service, consistency of care records and how people were supported to make decisions in line with the Mental Capacity Act 2005. Where action plans were in place, these had not always brought about consistent changes to the monitoring of people’s support.
There had been no registered manager at the service for over a year. During this time, there had been a number of different managers in post. Staff, relatives and professionals told us this had led to inconsistencies in the way people were supported, poor management oversight and a lack of support for staff. The provider was taking steps to recruit to this post and had made interim arrangements to provide more consistency.
Staff worked with a range of partners involved in people’s care and monitored people’s health needs. Partners told us that although there had previously been concerns regarding communication and information sharing, they felt systems were improving.