Collegiate House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

This is the first assessment for this newly registered service. This key question has been rated outstanding. This meant people were protected by a strong and distinctive approach to safeguarding, including positive risk-taking to maximise their control over their lives. People were fully involved, and the provider was open and transparent when things went wrong.

This service scored 97 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a strong, proactive and positive culture of safety, based on openness and complete honesty. Staff actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were always learnt to continually identify and embed good practice. For example, 1 person had a highly detailed, person-centred, and proactive positive behaviour plan in place. The plan provided staff with a comprehensive understanding of the person's needs, communication preferences, sensory profile, behavioural presentation, triggers, and the support strategies required to promote positive outcomes. Staff had a strong emphasis on prevention and early intervention. Detailed guidance supported staff to recognise baseline presentation, identify early warning signs, understand the functions of behaviour, and implement proactive strategies before behaviours escalated. This enabled staff to respond consistently and effectively, reducing the likelihood of distress and supporting the person to maintain emotional regulation. The provider had closely monitored this person’s incidents of distress and found a common theme within a particular time period during each month. Staff worked with professionals and as a result this person’s incidents of distress had reduced, this had improved their quality of life, including their day-to-day life and social inclusion. For another person, staff reflected on their support needs and identified that increasing their control over when and how support was accessed had a positive impact on their emotional well-being and reduced anxiety. Through the use of assistive technology, this person was empowered to request support when needed, promoting independence, privacy, and choice. Learning from this person-centred approach informed safer risk management strategies and contributed to a significant reduction in incidents. Positive outcomes were also evidenced by a substantial decrease in the individual's reliance on prescribed anxiety medication, demonstrating how embedding learning and innovation into practice improved both well-being and independence.

The provider always worked with people and healthcare partners to design, establish and maintain safe systems of care, in which safety was always well managed and monitored. They made sure there was always continuity of care, including when people moved between different services. Robust systems were in place to assess potential new admissions, with comprehensive pre-admission assessments undertaken to ensure the service could meet people's needs and to consider compatibility with people already living within the home. This included multiple visits and opportunities for people to become familiar with the environment, staff team, and their potential peers before moving into the service. A relative said, “[Name] transitioned from the family home to Collegiate House. We worked with the social worker, and we spent time looking for the best place for [name]. Collegiate House needed to assure us that they would be able to keep [name] safe...and yes, they did that. Staff carried out the necessary assessments required prior to transition. They even sent their staff into [name’s] college to shadow them, to watch and get to know them.”

Care records were of a consistently high standard, being detailed, person-centred, and focused on achieving positive outcomes. Information was recorded in a way that enabled it to be easily shared with external professionals, supporting effective multi-disciplinary working and informed decision-making. Staff proactively shared information, including behavioural monitoring and incident data, to provide professionals with a comprehensive understanding of people's needs, risks, and progress. This supported timely reviews and ensured support strategies remained responsive and effective.

The service worked collaboratively with a wide range of professionals and agencies to achieve positive outcomes for people. For example, the management team had recently worked closely with social workers and other stakeholders to facilitate a planned and successful transition for one person moving to another service. This demonstrated a commitment to supporting people throughout their journey, including when this involved moving on to a more suitable placement.

Without exception, professionals spoke highly of the service and the quality of support provided. Feedback consistently highlighted the professionalism of the staff team, their person-centred approach, and their ability to work collaboratively to achieve the best outcomes for people. Professionals also praised the service for the way it supported people through transitions, ensuring moves were carefully planned, well co-ordinated, and focused on maintaining people's well-being and continuity of care. A professional told us, “Overall, my experience of Collegiate House is very positive, and I hold the Collegiate service in high esteem. [Name] is an individual with multiple varying needs.I have found them to be unfazed by the challenges that [name] has brought to the service and a willingness to work collaboratively to find solutions. They have appeared committed to [name’s] general well-being and quality of life, and this extended to supporting the new staff team to manage their needs once [name] had transitioned to another service.”

The provider worked well with people and healthcare partners to fully understand what being safe meant to them and the best way to achieve that. Staff had a clear focus on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider always shared concerns quickly and appropriately. People were protected by a strong, open, and person-centred safeguarding culture. There was a clear commitment across the service to ensuring people were safe, listened to, and supported to live free from abuse, discrimination, avoidable harm, and neglect.

Without exception, people and their relatives spoke positively about the care and support provided. People told us they felt safe living at the service and were comfortable with the staff who supported them. A person said, “I like living here, it is good for people like me. Staff are better than where I used to live. Staff are great, they are kind to me.” Relatives consistently described staff as caring, compassionate, and highly responsive to people's needs. They told us they had confidence in the service and felt assured their family members were safe and exceptionally well cared for. A relative said, “[Name] has been here a couple of years it is a very good service; we have really good communication with managers. I can go to them with anything. [Name] is kept safe, staff are very good, very understanding.”

Without exception all staff told us people were kept safe and received high-quality support from a committed and caring team. Staff described leaders as approachable, supportive, and highly visible within the service. They told us managers promoted an environment where concerns could be raised openly, discussed constructively, and acted upon promptly.

Staff demonstrated a thorough understanding of safeguarding and their responsibilities to protect people from harm. They had received safeguarding training and were able to confidently describe how they would recognise potential signs of abuse, neglect, exploitation, or discrimination. Staff understood the importance of acting immediately if they had concerns and were knowledgeable about local safeguarding procedures and reporting pathways. They told us they had complete confidence in the management team to respond appropriately to any safeguarding concerns. However, they also understood their responsibilities to escalate concerns beyond the service if required, including to senior leaders, local authority safeguarding teams, and the Care Quality Commission (CQC). A staff member said, “I like it here, very good managers, we get lots of support from management, supervisions are very regular. I have had lots of training. Never had to report any safeguarding concerns, but if I needed to, I would go to my manager. I would be listened to. I can talk to them about any problems; I can go to them.”

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). In care homes, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). The service was working within the principles of the MCA, people had DoLS authorisations in place where required and staff adhered to conditions of each person’s DoLS. For example, 1 person’s condition was for a further decision specific capacity assessment to be completed, which had been actioned.

The provider always worked well with people to fully understand and manage risks by thinking holistically. Staff provided care that fully met people’s needs and was safe, supportive and enabled people to do the things that mattered to them.

The service demonstrated an outstanding and innovative approach to managing risks by continually learning from incidents, analysing trends, and developing highly personalised strategies to improve people's safety and well-being. Risk management was not limited to mitigating harm; it focused on understanding the underlying causes of behaviours, promoting independence, and improving quality of life. Risk assessments were exceptionally detailed, person-centred, and tailored to each person’s needs, preferences, behaviours, and goals. They clearly identified risks specific to the person and outlined proportionate control measures that reduced the likelihood of harm whilst supporting positive risk-taking, independence, and choice. Staff demonstrated a thorough understanding of these assessments and consistently applied them in practice. For example, for 1 person, staff worked closely with family members and behaviour support specialists to develop a bespoke crisis response plan following their admission to the service. Through detailed analysis of incidents and ongoing review of support strategies, the service implemented a range of proactive and least restrictive measures which significantly reduced the frequency, duration, and impact of behavioural incidents. Incident duration reduced, with a corresponding reduction in injuries experienced by both the person and staff.

Through analysis of incident data, staff identified a clear link between the person's well-being, anxiety, and pain. This enabled them to introduce anticipatory support measures, adjust care approaches during periods of increased vulnerability, and work collaboratively with healthcare professionals to implement appropriate treatment and support. As a result, incidents reduced significantly, from twelve incidents during the first seven months following admission to only two incidents during 2026. Positive behaviour support plans were regularly reviewed and updated following incidents, ensuring learning was embedded into practice and support remained responsive to changing needs. Records evidenced an improvement in their physical health and appearance following these periods of settled behaviours.

For another person, staff recognised that having greater control over how and when support was provided reduced anxiety and promoted emotional well-being. Assistive technology enabled the person to request support when required while maintaining privacy and independence. This approach supported safer risk management and was associated with a significant reduction in incidents and a substantial decrease in reliance on prescribed anxiety medication.

These examples demonstrated a strong culture of learning, innovation, and continuous improvement. Leaders and staff used information, incident analysis, and partnership working to develop highly personalised approaches to risk management that resulted in safer care, improved well-being, reduced restrictive practices, and significantly better outcomes for people.

The provider was fully aware of all potential risks in the care environment and controlled them well. They made sure equipment, facilities and technology supported the delivery of safe care. The service demonstrated an exceptionally person-centred approach to risk management by ensuring the people’s living environment was carefully tailored to meet their individual needs, preferences, and assessed risks. Adaptations had been thoughtfully implemented to promote safety whilst maximising independence, dignity, and quality of life. This included the provision of appropriate mobility aids, secure access arrangements, and personalised features that enabled 1 person to navigate and use their home safely and confidently. Innovative use of assistive technology further enhanced the person's independence and safety. Systems were in place which enabled them to request support when required whilst maintaining choice and control over their personal space. These measures supported staff to balance positive risk-taking with effective oversight, ensuring support could be provided promptly when needed. Staff told us that creating an environment that was truly designed around the person's needs had a significant positive impact on their well-being. The personalised adaptations and support arrangements helped reduce anxiety, increased independence, and contributed to a reduction in incidents of distress.

For another person, staff supported them to design and arrange their bedroom in a way that reflected their preferences and enabled them to safely engage in an activity they particularly enjoyed, which was moving furniture and belongings around their room. By recognising the importance of this activity to the person and adapting the environment accordingly, the service reduced the risk of injury whilst promoting choice, independence, and self-expression. For another person, the management team had undertaken detailed monitoring and analysis of incidents involving self-injurious behaviours. This learning was used to implement proportionate and least restrictive environmental adaptations within their bedroom to reduce the likelihood and impact of injury. These changes were carefully considered, regularly reviewed, and designed to balance safety with the person's rights and freedoms. This demonstrated how the provider recognised the importance of creating enabling environments that not only kept people safe but also supported them to thrive and achieve positive outcomes.

Several maintenance checks were in place to mitigate risks posed to people from the environment. This included fire safety measures, such as equipment checks and fire evacuation drills. People living at the service were also involved in fire safety evacuation drills, and had detailed, person centred personal evacuation plans in place. The service had a defibrillator in place within the service which could be used in the event of an emergency.

The provider made sure there were always enough qualified, skilled and experienced staff, who received thorough support, supervision and strong development opportunities. They worked together well to provide safe care that met people’s individual needs. People were supported on a one-to-one basis throughout the day and shared staffing arrangements during the night. This flexible approach enabled people to make meaningful choices about how they spent their time and ensured support was tailored around their individual preferences rather than fixed service routines. For example, people were regularly supported to attend social activities, events and concerts during evening hours, promoting choice, independence and community inclusion.

People benefited from support delivered by a stable and committed core staff team. Staff turnover was low, which meant people were provided with continuity of care and this enabled people to develop trusting and positive relationships with staff who knew them exceptionally well. A relative told us, “There is never any agency staff, and when new staff start, they have to shadow before they can work with [name]. Staff are highly trained to manage [name]. There are systems in place to manage [name’s] incidents. There has been a significant decrease in [name’s] incidents since living at Collegiate House.” Staff demonstrated a detailed understanding of people's individual needs, preferences, communication methods and support requirements. This consistency helped reduce anxiety and promoted people's emotional well-being and confidence.

Robust recruitment processes ensured staff were recruited safely and possessed the values, skills and attributes required to support people with a learning disability and/or autism. People were actively involved in the recruitment and selection of new staff. This meaningful involvement enabled people to influence who supported them and allowed managers to assess prospective staff's ability to engage positively and respectfully with people.

Staff received comprehensive training tailored to the needs of the people they supported. This included specialist training in epilepsy and the administration of rescue medication. As a result, one person was no longer restricted in their ability to access the community, significantly improving their quality of life, independence and inclusion. Staff also completed mandatory training alongside specialist learning in areas such as people specific positive behavioural support, personality disorder and autism awareness. Staff also received specialist training in regards to supporting people with a learning disability, and/or autism. A staff member said, “I have just completed my NVQ in care, this was supported by the provider. I have recently had my appraisal. The managers are great. People are well looked after here, in this service everyone is looked after, staff and people alike.”

The service demonstrated a strong commitment to developing and sustaining a highly skilled workforce. Senior staff had completed 'train the trainer' qualifications in medicines management and positive behavioural support, enabling them to provide effective coaching, competency assessments and ongoing oversight of staff practice. This helped ensure people received safe, consistent support in line with current best practice.

Leaders were committed to investing in staff development and creating a positive workplace culture. The registered manager had recently been recognised by the provider for achieving a distinction in a leadership qualification, reflecting their commitment to professional development and service improvement. Staff consistently told us they felt exceptionally well supported in their roles. They received regular, meaningful supervision and opportunities to reflect on practice, share ideas and contribute to service development. Staff described a culture where their wellbeing and professional growth were valued and encouraged. A staff member said, “We (staff team) operate on the best level we can, and work how we should do. The people living here are supported to live their best life.”

These arrangements reflected the principles of Right Support, Right Care, Right Culture. The provider had ensured there was the right mix of skills, experience and values across the staff team, enabling people to receive highly personalised support which promoted independence, dignity, choice and positive outcomes.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. The service maintained a clean, safe and welcoming environment, with effective infection prevention and control systems in place. Regular audits, staff training and appropriate use of personal protective equipment (PPE) helped ensure high standards were consistently maintained.

People were encouraged to maintain their own living spaces and participate in household tasks, promoting independence while supporting safe infection control practices. Individual arrangements, including personal laundry facilities and bathrooms where appropriate, reduced the risk of cross-contamination. The service also considered staff safety through the use of specialist protective equipment when required. Relatives consistently praised the cleanliness and presentation of the home, which supported people to live safely, comfortably and with dignity.

The provider always made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff always involved people in planning, including when changes happened. Medicines were managed exceptionally well, with a strong focus on promoting people's well-being whilst reducing the risk of unnecessary medicines use. The service demonstrated a clear commitment to the principles of STOMP (Stopping Over Medication of People with a Learning Disability, Autism or both) and worked proactively with healthcare professionals to ensure medicines remained appropriate, effective and clinically indicated.

People had detailed, person-centred medicines support plans which clearly outlined their individual needs and preferences. Regular medicines reviews were undertaken in collaboration with GPs, psychiatrists and specialist professionals. These reviews had achieved positive outcomes for people. For example, 1 person's anti-psychotic medication had been successfully reduced following collaborative working with the psychiatry team. Another person had progressed from requiring regular daily anxiety medication to only requiring it on an as-required basis, significantly reducing their reliance on medicines and improving their independence and quality of life.

The provider had developed robust quarterly STOMP reviews which were shared across their wider services, demonstrating a commitment to improving practice and reducing over-medication. Staff completed regular training, competency assessments and ongoing observations to ensure medicines were administered safely and consistently.

Comprehensive auditing systems, stock checks and governance processes supported safe medicines management. Controlled drugs were stored and monitored appropriately, and detailed protocols guided staff when administering medicines prescribed on an as-required basis. This included clear guidance for epilepsy rescue medication, ensuring staff understood exactly when administration was required and when emergency medical assistance should be sought. Where errors occurred, leaders demonstrated a transparent learning culture, implementing additional training, supervision and competency assessments to mitigate risks and improve practice.