United Response - 66 & 66a Lemsford Road

Ratings

• Overall

  Inadequate

• Safe

  Inadequate

• Effective

  Requires improvement

• Caring

  Requires improvement

• Responsive

  Requires improvement

• Well-led

  Inadequate

Our view of the service

We undertook an inspection of United Response – 66 & 66a Lemsford Road. We visited the service on 8 July 2025 and 15 July 2025. This inspection was prompted by a review of the information we held about the service and intelligence received which suggested there was potentially a risk to people receiving support. United Response – 66 & 66a Lemsford Road is a care home providing personal care to people. The service provides support to people with a learning disability and autistic people. At the time of our inspection there were 9 people living there. 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 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. We considered this guidance as there were people using the service who have a learning disability and/or who are autistic. The service did not meet this guidance. We found elements of care which was unsafe. There were concerns around risk management, restrictive practices, and staff training; particularly in relation to supporting people with complex health needs such as epilepsy. Some incidents had not been appropriately notified, and restrictive practices were in place without clear legal justification or best interest decisions having been recorded. These issues posed risks to people's safety and wellbeing and required urgent attention. Page 2 of 20 Inconsistencies in care delivery were also evident. People were not always treated as individuals, and there were disparities in how communication, independence, and meaningful activity were supported. Care plans lacked detail and accessibility, and did not consistently reflect people's goals, preferences, or aspirations. This limited people's ability to be involved in decisions about their care and reduced opportunities for promoting autonomy and wellbeing. The application of the Mental Capacity Act was inconsistent, with missing assessments and restrictive practices not always considered in the context of best interests. Staff were not all equipped to communicate effectively with people, and in some cases, missed opportunities to engage meaningfully. Feedback from relatives was mixed. While some felt their loved ones were safe and well cared for, others raised concerns about safety, wellbeing, and communication. The management team responded by implementing new ways for families to make contact, which was a positive step towards improving transparency and engagement. The provider had begun to take steps to improve governance, oversight, and learning from incidents. A weekly review process had been introduced to support better monitoring and promote a culture of safety. However, further work was needed to embed these systems and ensure they led to sustained improvements. The service was undergoing a period of significant change at the time of our inspection, with a new management team and senior leadership working to improve the quality of care and support provided. Internal audits had identified key areas requiring attention, and there was evidence that actions were being taken to address these. Staff reported feeling more supported and able to approach the current manager, reflecting a more open and positive culture beginning to emerge. Overall, the service was on a journey of improvement. There was a clear commitment from the new leadership to raise standards and deliver more consistent, person-centred care. Continued focus on staff development, communication, personalised support, and robust governance will be essential to achieving and maintaining high-quality outcomes for people using the service. We found a breach in regulations for safe care and treatment, person centred care, need for consent and good governance. The provider did not ensure people were supported in the least restrictive way, people did not always have the choice and control of the daily life. People were not always supported by appropriately skilled staff. The provider’s governance systems were not always robust to identify areas of improvement, they were unable to evidence how improvements were then embedded in the services. We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor. In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/ or appeals have been concluded.

People's experience of this service

We met everyone living at the service. We communicated with 4 people and 5 relatives about their experience of the care provided. Where people who used the service were unable to talk with us, we used different ways of communicating including using Makaton (a type of sign language). We are improving how we hear people's experience and views on services, when they have limited verbal communication.