Updated 10 March 2025
Date of assessment: 28 and 29 April 2025. The service is a care home without nursing providing support to people with learning disabilities and/or autism.This assessment took place due to concerns received about people’s care, risks, medicine, staffing and governance oversight at the service.
The provider was in breach of the legal regulations relating to person-centred care, risk management, safety of premises and equipment, staff recruitment, need for consent and good governance. The provider and the registered manager did not demonstrate they had robust quality assurance systems and governance processes which operated across all levels of the service. The provider had not followed their own policies or best practice guidance to effectively assess, monitor and mitigate any risks relating to the health, safety and welfare of people using the service and others. This included not using safe recruitment procedures to employ staff, not ensuring premises and equipment were safe to use including fire safety and medicines records keeping. This put people at increased risk of harm. The provider needed to review and improve staff deployment and how staff's training needs and skills were managed in order to meet some people's specific needs. Staff did not always support people to take part in meaningful activities and ensure people could pursue their interests in their local area with people who had shared interests and achieve their aspirations and goals.
Staff did not always have the right knowledge and skills to encourage and enable people to take positive risks, respond with kindness and understand individual needs. People were not always supported by staff who understood their different range of needs or sensitivities.People’s relatives were involved in reviewing and planning their care. However, we were not assured people’s views and decisions were fully considered. The provider did not ensure staff carrying our capacity assessments and best interest decisions were knowledgeable and skilful to complete those.We were not always assured the provider, the management team and staff were working together to ensure the risks of a closed culture were minimised so that people received support based on transparency, respect and positive culture in the service.Staff told us how they protected people from abuse and how they would report such incidents. The service worked with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.For services for people with a learning disability and autistic people, include reference to Statutory guidance: Right Support, Right Care, Right Culture (RS, RC, RC) where appropriate and that we have assessed against it. At the end of the summary add the following statement so the reader can understand what right care etc means.We have 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.