Updated 26 February 2025
Date of inspection: 12 March 2025 to 7 April 2025.The inspection was prompted in part by an external concern received relating to an incident in which a person who used the service later died in hospital.This incident is subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of the incident. However, the information shared with CQC about the incident indicated potential concerns about the management of risk and governance. This inspection examined those risks.
This inspection identified breaches in relation to person-centred care, need for consent, safe care and treatment, good governance and staffing.
The provider was registered to provide a service to people with a learning disability or were autistic. Not all people using the service had a learning disability or were autistic.
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.
‘Right support, right care, right culture’ (RSRCRC) is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it. The service failed to meet the principles of this guidance.
People’s care records did not contain information which was person-centred to ensure the consistent provision of person-centred care by staff.
The registered manager did not ensure capacity assessments were carried out in line with the requirements of the Mental Capacity Act 2005 and associated code of practice. People’s capacity to consent to their care and treatment had not always been considered.
Staff did not have necessary training in place to keep people safe or support people with a learning disability and autistic people. Our inspection found elements of the care did not meet the expected standards. Not all staff were trained when supporting people with a learning disability and autistic people, nor in relation to choking, nutrition and hydration and glucose monitoring. People did not receive person-centred care as staff did not have detailed guidance to support them in the delivery of safe care and treatment.
Medicine competencies were not carried out to ensure staff were safe to administer medicines. Following the assessment, the provider submitted a medication competency assessment for one member of staff. However, we were not assured staff were safe to administer medicines.Recruitment process did not evidence staff were interviewed as there was no documentation in place to evidence this.
The provider did not have systems and processes in place to support oversight of the service and therefore was not doing all that is reasonably practicable to mitigate risks, improve practice and keep people safe. There were limited records to show audits or actions were undertaken to keep people safe.
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.
This service is being placed in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we user our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.