Updated 18 March 2025
Date of Assessment: 22 to 28 May 2025.
This assessment was completed to check necessary improvements had been made to address the issues identified during our previous assessment.
We assessed all quality statements under 3 key questions; Safe, Effective and Well-led. The service is a care home providing support for to up to 8 people with learning disabilities or autistic people. At the time of our inspection 8 people were using the service.
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.
The provider was previously in breach of regulations in relation to safe staff recruitment and the environment of the service. Improvements were found at this assessment and the provider was no longer in breach of these regulations.
The provider was previously in breach of the regulation in relation to staffing. Improvements were not found at this assessment; weekend staffing arrangements were at a level continued to limit people’s access to the community and opportunities to engage with activities they enjoyed. The provider remained in breach of this regulation. Following feedback, the registered manager took action to increase staffing levels at the weekend to reduce the restrictions to people’s ability to access the community.
At our previous assessment the provider was in breach of regulation in relation to safe care. Some improvements had been made to the management of risk within the service and the frequency of incidents between 2 people, which had previously been a concern, had reduced. However, when an incident had occurred, this had not been documented in the records of one of the involved parties making it impossible for people’s full experiences to be understood. There were no protocols available to guide staff when administering medicines to be used ‘as required’. This meant there was a risk staff might not be consistent in their approach. The provider remained in breach of this regulation.
At our previous assessment we identified a breach of regulation relating to the management of the service. Governance systems had improved but they were not yet sufficiently robust to ensure full compliance with the requirement of the regulations and the provider remained in breach of this regulation. However, changes had been made to the service’s leadership arrangements and 2 team leader roles had been introduced to support the registered manager and provide additional leadership to the staff team. People were comfortable requesting help from staff who valued people’s skills and achievements.
Although the service’s performance had significantly improved, we identified 3 repeated breaches of the regulations relating to, safe care and treatment, staffing and governance.
We have asked the provider for an action plan in response to the concerns found at this assessment.