During an assessment under our new approach
Date of assessment: 10 November to 27 November 2025. We completed this assessment in response to concerns we had received about the service. The service is a residential setting made up of individual homes providing support to people with a learning disability, and or autistic people for up to 5 people. There were 2 people living at the service at the time of our assessment who received a regulated activity. We assessed the home 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. We found the home was not always within these principles. We found 4 breaches of regulations relating to person-centred care, need for consent, safe care and treatment and good governance.
Right support: There was not a consistent approach when people presented behaviours that may challenge. People’s change in needs had not been effectively considered. Staffing levels impacted how people received their care. Protocols were not readily available for staff to follow. There were contradictions across a range of people’s care records. Staff used different approaches when supporting people. People completed similar activities almost every day with not much exploring of other activities people may like. Staff had access to an on-call system; however, this system was not effective.
Right care: Staff reported the home was regularly understaffed and relied on agency care staff; however, agency staff did not have the correct skill base to work with people. There were no clear plan or guidance for staff to follow when there were not enough staff on site to meet the needs of people safely. Staff were not sufficiently trained to undertake their roles. Where it was identified in care plans, communication tools should be used, we found no evidence of this. The provider was not working within the principles of the Mental Capacity Act 2005.
Right culture: There had been managerial changes at the home which had a negative impact on the home. Lessons were not learnt to identify and embed good practice. Staff described the team as having low moral with no direction from managers. Systems were not effective in making sure people, and their relatives where appropriate, were involved in developing their care plans. Governance systems continuously failed to assess, monitor, and improve the quality and safety of the home,
People expressed they wanted support from staff who knew them well; however, this was not being achieved. People were frequently supported by unfamiliar staff which caused them anxiety and distress. We were informed people had expressed they did not want agency staff to work with them, but there was no evidence action had been taken to respond to or address these concerns. People’s wishes and choices were not always considered in how they received their care. There was limited evidence the service sought feedback from people or their relatives about their experiences of care. However, relatives told us they valued the support provided by the more experienced staff members.