South Street

Date of Assessment: 7 July 2026 to 17 July 2026. South Street is a care home providing support to adults of all ages, living with learning disabilities or autistic spectrum disorder.

This assessment was carried out to follow up on enforcement action we took after the last inspection. At the previous assessment the provider was found to be in breach of legal regulations relating to safe care and treatment and good governance. At this inspection the provider remained in breach of those regulations and additional breaches of regulations were identified relating to safeguarding adults from abuse and safe staffing.

We assessed the service against ‘Right support, right care, right culture’. This guidance supported judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choice, independence and access to local communities that most people take for granted. We found the provider was not providing care and support which met with the principles of this guidance.

We continued to find serious concerns with regards to people’s safety. Risks were not always safely managed, and people were exposed to the risk of harm. Staff were not always following risk assessments to keep people safe and care plans were not always accurate or up to date. Health professional advice was not always followed and there were risks to people’s safety from the care environment.

There were continued concerns with the ineffective oversight of the service and poor management which meant risks related to the service were not identified and effectively managed through these systems. People were not supported by sufficient staff to meet their needs and preferences. Systems in place to identify abuse, manage medicines and review peoples care needs were ineffective.

People were not consistently treated with kindness and compassion and were not fully engaged in making choices. People were not always asked for consent to their care. Staff could not always provide care which was person-centred and gave people equity in access and outcomes due to the staffing levels in the home. People were not consistently supported to access the community.

However, staff have access to evidence-based tools to aid assessment and support planning outcomes are considered and goals set for people to achieve. People had individual care plans in place and this took account of their individual preferences, choice and independence. Bedrooms were personalized and people had individual communication plans in place to support them to communicate their needs.

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.

In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.

South Street provides accommodation for a maximum of 8 people with a learning disability and/or autistic people requiring personal care. There were 8 people living at the home when we visited.

The last rating for South Street under the previous provider was requires improvement. This provider was registered with us on 24 July 2024, and this is their first assessment. We have identified breaches in relation to safe care and governance systems.

We found safety events had not always been appropriately reviewed and used for understanding and learning. Environmental and infection prevention and control (IPC) risks had not always been identified and acted upon. Gaps in staff training had not always been identified and acted upon. This meant people were at risk of receiving unsafe care and support. Medicines were not always managed safely. Medicines were not always administered as prescribed, and guidance was not always in place for topical and ‘as required’ medicines. Governance systems were not always effective at identifying risks to people. Which placed people at an increased risk of harm.

We expect health and social care providers to guarantee 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' 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.

We saw aspects of ‘Right support, right care and right culture’ guidance was delivered by the service. For example, we observed the model and culture of care and size and layout of the service promoted people being able to exercise choice, control and independence in how they chose to their lives. This was reflected in the feedback we received from staff, who demonstrated an awareness and commitment to promoting and supporting people’s choice and control. The service was also well-located in a community with easy-to-access amenities, which people accessed and engaged with on a regular basis.

We found some safety event records which showed people had been harmed as a result of behaviours from another person had not been effectively reviewed by leaders, which could have supported understanding and learning of such events. There were also inconsistencies in relation to reporting safeguarding concerns to external partners and, while they told us how they would raise concerns should they need to, not all staff had completed safeguarding training.

A safeguarding policy was in place, which staff understood.

Some care plans and risk assessments provided clear, person-centred and detailed, and staff were knowledgeable of people’s needs. People interacted positively with staff, who treated them with kindness and understanding and sought to provide person-centred care which promoted people’s choice, control and independence. Staff were positive about the support they received from leaders.

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.