Irchester 170

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

This means we looked for evidence that people were protected from abuse and avoidable harm. At our last inspection we rated this key question requires improvement. At this inspection the rating has changed to good. This meant people were safe and protected from avoidable harm.

The provider was previously in breach of the legal regulation in relation to
safe care and treatment, safeguarding and safe staffing. Improvements were found at this assessment, and the provider was no longer in breach of this regulation.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Since the last inspection the provider had strengthened their approach to oversight which helped create a safer and more confident learning culture across the service. More robust systems and processes were introduced to ensure monitoring was consistent, meaningful, and clearly understood by staff. These improvements supported a positive learning environment where lessons from accidents and incidents were routinely identified, shared, and embedded into everyday practice.

Additional BOC (behaviour of concern) analysis, reviewed by PBS (positive behaviour support) leads and PBS coaches, had further enhanced this approach. As a result, the management team could demonstrate the implementation of timely updates, review care plans effectively, and ensure that learning translated into actions that improve care quality and keep people safe.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Safe pathways and transitions had been in place across the residential service, supporting people to experience stable and well‑planned long‑stay placements. Clear processes ensured that transitions into, within, and out of the service were coordinated, person‑centred, and guided by thorough risk assessments. Staff received the information they needed at the right time, enabling them to understand each person’s needs and provide consistent, safe support. Strong communication between teams, external professionals, and families meant that changes in care were anticipated rather than reactive, reducing unnecessary disruption. These systems helped maintain continuity, promoted people’s wellbeing, and ensured that emerging risks were identified early and acted upon promptly.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated 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 shared concerns quickly and appropriately.

The provider had up‑to‑date policies and procedures in place, and staff had completed the relevant safeguarding training to ensure they understood how to recognise and report concerns. Clear reporting pathways supported prompt escalation, and safeguarding information was accurately recorded and reviewed. The service worked effectively with external partners, including local safeguarding teams, health professionals, and commissioners, ensuring that concerns were explored collaboratively and risks were managed transparently. This strong partnership approach helped maintain people’s safety and ensured safeguarding actions were timely, appropriate, and focused on protecting those living in the service.

Deprivation of Liberty Safeguards (DoLS) were managed well, and the provider ensured applications were submitted promptly and monitored effectively. Authorisations were clearly recorded, regularly reviewed, and shared with relevant professionals. This meant people’s rights were protected, and any restrictions in place were necessary, time‑limited, and used only to keep people safe.

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

Detailed Positive Behaviour Support (PBS) plans that set out how to support each person at different stages of distress, including during periods of crisis. These plans helped staff recognise early indicators of escalating anxiety and respond in ways that reduced the likelihood of further distress. Individual risk‑mitigation records were in place for all assessed risks, including social, health and environmental factors, and outlined proportionate measures to promote people’s safety while supporting their independence.

Positive risk‑taking was clearly embedded within the service and reflected the principles of Right Support, Right Care, Right Culture. People were supported in ways that promoted choice, independence and autonomy, with staff working alongside individuals to identify meaningful opportunities and put proportionate plans in place to enable new experiences safely. One person recently achieved a personal goal of visiting the seaside and riding a ferris wheel, with staff offering reassurance and thoughtful preparation to ensure the experience was both safe and enjoyable.

Two people who enjoy each other’s friendship had previously been unable to share transport due to historical risks. Through a positive risk‑taking approach, these risks were reviewed and creative, person‑centred strategies were introduced. They are now able to travel together and have successfully enjoyed visits to the bowling alley, discos and local eateries.

These examples demonstrate a culture that values people’s rights, promotes dignity and encourages meaningful connections, ensuring individuals receive the right support and experience care that enhances their quality of life.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Although staff were committed to supporting people safely, environmental risks were not always managed effectively. Communal areas, including the laundry room, were cluttered and not kept to an appropriate standard of organisation.

Cleaning products and other hazardous items were accessible in this space, creating avoidable risks for people who may not recognise the potential dangers. While environmental checks were carried out, actions to address these issues were not completed promptly, allowing hazards to remain in place longer than necessary. These shortfalls demonstrated gaps in oversight and environmental safety management, limiting the provider’s ability to provide consistently safe care.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Staffing was safe and effective; the provider had taken proactive steps to ensure the team had the right skills and support to meet the needs of people living in the service. Additional training had been introduced, including specialist areas such as BOC (behaviour of concern) effective recording, which helped staff give clear accounts of incidents and gather the right information to support reflective practice. Relatives confirmed staff training had improved. One relative told us, “Staff training has improved and they are maintaining a good level of care”.

Rotas viewed between December 2025 and January 2026 showed staffing was consistently arranged to meet each person’s individual commissioned hours, ensuring people received the support they were entitled to.

New roles had also been developed to strengthen the management team and maintain effective oversight of staff practice. The senior role and practitioner lead roles were clearly defined, this additional resource ensured staff had the guidance, supervision and day‑to‑day support they required. These improvements contributed to a well‑organised, skilled and responsive workforce that supported safe and effective care.

Staff were recruited safely, the provider had effective processes in place to ensure only suitable people were employed to work in the service. Relevant pre‑employment checks had been completed, including references, identity verification and Disclosure and Barring Service (DBS) checks. These measures helped ensure the workforce was safe, competent and appropriately vetted to support people living in the service.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The service required improvement in its approach to infection prevention and control, as standards of cleanliness and environmental upkeep were not consistently maintained. People’s rooms required more regular and thorough cleaning to ensure they remained hygienic and safe. Communal areas, including the kitchen and laundry room, were not kept to an appropriate standard, with visible dirt and unclean areas that had not been addressed effectively.

The environment was visibly run down, with damaged flooring, worn work surfaces and chipped paintwork that made effective cleaning difficult and increased the risk of cross‑contamination. Laundry areas and through‑ways showed signs of ingrained dirt, and storage arrangements created obstacles to maintaining safe and hygienic cleaning practices.

Systems and processes in place to monitor and improve IPC (infection prevention control) and environmental checks could be strengthened, as we found that not all checks and routines had effective oversight. This lack of consistent monitoring contributed to the deterioration of the environment and increased the risk of cross‑contamination or potential infection. Although staff understood their responsibilities, cleaning schedules and environmental audits were not always carried out reliably, leading to avoidable lapses in hygiene. Improvements were needed to ensure IPC processes are robust, consistently implemented and supported by a well‑maintained environment.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People received their medicines safely and in line with best practice for learning disability services. Staff had a clear understanding of each person’s needs and supported them in ways that promoted independence, dignity and choice. Medicines were stored securely, administered safely and recorded accurately, with regular audits helping to identify and address any issues promptly.

The provider had up‑to‑date policies and procedures in place to ensure the safe management of medicines, and staff were familiar with these expectations. People were involved in decisions about their medicines at a level that suited them, and staff used accessible communication tools to support understanding.

The service worked closely with health professionals to ensure medicines were reviewed regularly, including psychotropic medicines, in line with STOMP (stop over medicating people) principles. This collaborative approach helped ensure people only received medicines that were necessary and beneficial, reducing the risk of over‑medication and promoting positive health outcomes.