Updated 24 February 2025
Date of assessment: 07 July to 06 August 2025. A comprehensive assessment was carried out due to concerns received about the quality of the service. This service is providing care and support needs to autistic people and people with a learning disability. At the time of our assessment 16 people were living in the service.
We assessed the service against the ‘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 provider had failed to meet these standards.
We attended site unannounced on 07 July 2025 and identified concerns within the service, We attended the service on 08 July 2025 unannounced again and following these visits we took enforcement action. We continued to assess the service and re-attended site the 05 August 2025 to be assured risks we had identified on the previous visits were mitigated. We found people were not always safe and protected from harm due to the service’s lack of processes and the condition of the environment. There was a closed culture within the service and incidents were not reported and lessons were not learnt. There was not a safe number of staff to meet people’s needs and staff were not trained appropriately. Recruitment practice was not safe because the service failed to check staff were suitable to support people
People’s care plans and risk assessments did not reflect their care and support needs. We identified restrictive practices within the service through observation and review of records. This evidenced that people were not in control of their care and support needs. People required appropriate monitoring of health conditions, and this was not happening and posed a risk of harm to people in the service.
The provider and leaders had a lack of knowledge and skills to lead effectively. When we began our assessment there was a registered manager in place, they then resigned, and the provider recruited a new manager who began towards the end of our assessment. There was minimal systems and processes in place to guide staff and manage their conduct. There was no oversight within the service and a lack of audits. Audits that were completed were inaccurate. Notifiable safety incidents and statutory notifications were not reported.
The provider was in breach of 8 legal regulations relating to person-centred care, dignity and respect, need for consent, safe care and treatment, safeguarding service users from abuse and improper treatment, good governance, staffing and fit and proper persons employed. This service is being placed in to 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 use our enforcement powers in response to inadequate care and provide a time frame within which providers must improve the quality of the care they provide.