Updated 1 December 2025
At the time of our assessment, there were 4 people living at the service. We visited on 9 and 15 December 2025 and 12 January 2026 following concerns raised about the service. During this assessment, we reviewed all quality statements under each of the five key questions.
We assessed the service against Right Support, Right Care, Right Culture to determine whether people with a learning disability and autistic people were supported in ways that promoted dignity, equality, choice, independence and access to their community.
Right Support
The manager demonstrated an understanding of these principles and applied some elements in practice, for example by promoting aspects of choice and control and encouraging person‑centred approaches aligned with human rights‑based care.
Right care
The provider did not consistently provide care which upheld people’s dignity, privacy and individual needs. While some staff demonstrated warmth and understanding this was not embedded across the team which meant care and support was inconsistent.
Right culture
Governance and oversight were not effective in identifying and driving improvements or ensuring a consistent, rights based culture. The culture of the service did not consistently promote people’s rights, dignity or inclusion. Leaders did not always model or embed the organisation’s values. Care and support were inconsistent.
These principles were not consistently embedded, and we observed practices which did not uphold or support them.
The provider used an electronic care system; we found some sections were incomplete or lacked sufficient detail. Where people lacked capacity to make specific decisions, the Mental Capacity Act (MCA) was not always applied in line with legal requirements. Care planning and risk assessments were inconsistent in quality, and key information was not always identified, recorded or mitigated. Staff had not received all the training required for their roles, including learning disability and autism training at the appropriate level, which meant they did not always have the skills or knowledge required to provide safe or effective support.
Medicines were not always managed safely. Governance systems were not robust enough to ensure adequate oversight of practice or the environment, and leaders had not identified or addressed the shortfalls we found.
At this assessment, we found 5 breaches of regulation in relation to safe care and treatment, person‑centred care, dignity and respect, and good governance.