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Inspection carried out on 30 July 2019

During a routine inspection

We inspected the service on 30 and 31 July and 6 August 2019.

About the service: Bedborough House is a residential care home and was providing personal care to six young adults at the time of the inspection. The service can support up to eight people with Autism and/or other learning disabilities. The home consists of four en-suite bedrooms and four flats which have en-suite bedrooms and a kitchenette. There is also a communal lounge and kitchen available for people to use.

The service had not been developed and designed in line with Registering the Right Support and other best practice guidance. Registering the Right Support ensures that people who use the service can live as full a life as possible and achieve the best possible outcomes. The principles reflect the need for people with learning disabilities and/or autism to live meaningful lives that include control, choice, and independence. People using the service had not received planned and co-ordinated person-centred support that is appropriate and inclusive for them.

People’s experience of using this service and what we found : People were not supported to have maximum choice and control of their lives. Staff had not always supported people in their best interests even though the policies and systems in the service supported this practice. We were not able to converse with all people fully, however two people agreed that staff were caring.

The service didn’t apply the full range of the principles and values of Registering the Right Support and other best practice guidance. These ensure that people who use the service can live as full a life as possible and achieve the best possible outcomes that include control, choice and independence.

The outcomes for people did not fully reflect the principles and values of Registering the Right Support for the following reasons; limited independence and limited inclusion e.g. People did not receive the activities of their choice and were not involved in the local community.

There were widespread and systemic failings identified during the inspection. The quality and safety monitoring systems used by the provider were not fully effective in ensuring the quality of service provision and mitigate risks to people. This did not ensure people were treated with kindness, dignity and respect.

The provider had failed to make appropriate statutory notifications; notifications tell us about significant events that happen in the service. We use this information to monitor the service and to check how events have been handled. Safeguarding incidents had not been identified and reported.

The guidance within peoples' risk assessments were not always followed by staff and records used to monitor peoples' health were not always completed. This exposed people to risks of neglect and unsafe or inappropriate care or treatment. People had access to healthcare professionals however we were not assured that staff always identified when referrals were required. People did not always receive their prescribed medicines as required.

The environment was not maintained effectively, and there was an infection control risk to people using the service.

The provider had a complaints procedure however, not all complaints had been recorded as such or investigated following the provider's complaints procedure.

For more details, please see the full report which is on the CQC website at

Rating at last inspection: The last rating for this service was Good (August 2018).

Why we inspected : The inspection was prompted in part due to concerns received about medicines, staffing, people’s safety, access to activities and record keeping. A decision was made for us to inspect and examine those risks.

We have found evidence that the provider needs to make improvements. Please see all of the sections of this report.

Enforcement: We have identified breaches in relation to medicines, the environment, safeguarding, dignity and respect, i

Inspection carried out on 28 April 2018

During a routine inspection

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[Care home name] is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Describe the care home's premises, for example:

(The care home) accommodates xx people in one adapted building.


The care service has been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen.' Registering the Right Support CQC policy

'A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.'