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Disabilities Trust - 25 Welby Close Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 15 November 2019

About the service

Disabilities Trust - 25 Welby Close is a care home without nursing. The service supported three people with learning disabilities or autism. The service is situated in a quiet residential area of Maidenhead, Berkshire. The house has two


The service was not always developed and designed in line with the principles and values that underpin Registering the Right Support and other best practice guidance. This ensures that people who use the service can live as full a life as possible and achieve the best possible outcomes. The principles reflect the need for people with learning disabilities and/or autism to live meaningful lives that include control, choice, and independence. People using the service did not always receive planned and co-ordinated person-centred support that is appropriate and inclusive for them.

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

There were not always clear safeguarding systems in place to protect people from risk of abuse.

It was evident where a safeguarding incident had occurred, the management team had not always followed their policies and procedures and informed the local authority.

Risks to people were not always managed safely. People’s risk assessments were not reviewed on a regular basis to ensure they were kept up to date and reflected any changing needs.

Risk assessments were not person centred. All care files contained risk assessments for people which were all initially scored as medium risk. There was no clear matrix or scoring tool to help staff determine what risk rating the assessment should be scored.

Required staff recruitment checks including criminal checks with the Disclosure and Barring Service were carried out. However, the management team could not always evidence they had taken a full employment history of staff. We could not be assured staff were been supported by people who had undergone the appropriate employment checks.

Medicines were not always managed safely by the service. For example, where people were prescribed 'as required' (PRN) medication, the service did not always have protocols or guidance in place to ensure that staff knew when to administer PRN medicine.

We recommended the provider consider current legislation related to the safe management of medicines and update their practice accordingly.

The management team used systems and processes to monitor quality and safety in the service. However, We identified some inconsistencies in record keeping that had not been identified from their quality assurance processes

Services registered with Care Quality Commission (CQC) are required to notify us of significant events, of other incidents that happen in the service, without delay. The management team had not consistently notified CQC of reportable events within a reasonable time frame. Three incidents had been identified as being unreported.

People had an autism profile in their care files that clearly highlighted their social, physical, communication and sensory needs to help guide staff when engaging with people.

People were involved in decisions about the decoration of their rooms. All bedrooms were personalised and set out in the way that people wanted. All people had their own bathroom facilities to use.

All people had communication profiles so that staff could clearly see how a person liked to be supported.

People’s individual care and support needs had been assessed, with assessments in place for areas such as mental capacity, medication, communication and interaction profile.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

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 28 March 2017).

Why w

Inspection areas


Requires improvement

Updated 15 November 2019

The service was not always safe.

Details are in our safe findings below


Requires improvement

Updated 15 November 2019

The service was not always effective.

Details are in our effective findings below.



Updated 15 November 2019

The service was caring.

Details are in our caring findings below.


Requires improvement

Updated 15 November 2019

The service was not always responsive.

Details are in our responsive findings below.


Requires improvement

Updated 15 November 2019

The service was not always well-led.

Details are in our well-led findings below.