Updated 24 June 2025
Date of Assessment: 3 July to 31 July 2025.
We carried out a comprehensive assessment in response to concerns we had about the service.
The service provides personal care for younger and older people with a learning disability. People are supported in a supported living home with their own tenancy agreement from a landlord.
At the time of our assessment there were 30 people being supported with personal care. As part of our onsite assessment activity, we visited the registered office and 10 supported living homes supported by this 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 the principles of this guidance.
People’s needs and risks were not being effectively assessed, and medicines incidents were not managed effectively. People’s Personal Emergency Evacuation Plans (PEEPs) were not up to date, and we found people’s medicines were not being managed safely. We also found infection control practices were poor.
Staff did not always understand how to meet people’s current needs because people’s care plans and risk assessments did not provide adequate information and guidance. This meant the provider had failed to have systems in place to ensure staff had all the up-to-date information they needed for people to receive consistent care.
We identified shortfalls in staff supervision and training. One member of staff told us, “I’ve not had one [supervision] for a very long time, I’m not able to recall when I had one in the last 5 years.” Another staff member told us, “We don’t get regular supervision.” We were also told, “I can’t recall getting one [supervision] in the last couple of years,” and “I’ve never been asked about my well-being by a manager.”
Staff told us they did not feel supported by local leaders. A staff member told us, “I think we are under supported here.” We found that visits by service managers had not been supportive and were ineffective. There was a disconnect between support local leaders told us they were delivering and what staff were experiencing. A staff member told us, “Face to face visits would go a long way to improve staff morale.” Another staff member told us, “It would be fair to say that until recently, I did not always feel supported at the local level”. We were also told by a staff member, “Service managers are not always visible” and that, “Visits are often on the doorstep, they say they can’t come in because it’s supported living.”
Some staff told us they did not know who senior leaders responsible for the service were and they didn’t visit homes. A staff member told us, “The [registered] manager never comes here [name of home], and I couldn’t tell you who the regional manager is.” Another staff member shared with us it was a shame a visit from the area and regional manager had only been prompted by the CQC assessment." The provider confirmed that the Regional Operations Manager had visited services on three occasions in 2024 and once in 2025. Visits were also completed in 2025 by the Chief Executive Officer and the Executive Director of Personal Support England. Service managers and support staff had also been invited to roadshows with the senior management team.
The oversight of the service was not adequate. Systems were not robust enough to assess, monitor and improve the quality and safety of the service being provided to people. Audits completed were ineffective and systems and processes did not support learning and improvement.
We met with the provider during our assessment to share the concerns we had identified. The provider was receptive to the feedback we shared and sent us an action plan to outline the steps they were taking to improve the oversight of the service and address the shortfalls we had identified. The provider committed to sharing regular updates to demonstrate the improvements being made and told us they were using our findings to reflect how they had not met the standard they expect of their services. The provider also told us they would be using this reflection and learning, to feed into their various committees, to consider what changes needed to be made as a result.
The provider was found to be in breach of 3 legal regulations relating to safe care and treatment, good governance and staffing. Although the provider shared assurances that action was being taken in relation to the findings during our assessment, further work was required ensure these actions lead to sustained change and improvement across the service.
The service has been rated inadequate overall. The service is being placed in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provides a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.
In instances where CQC have decided to take civic or criminal enforcement action against a provider, we will publish this information on our website after any representations and/or appeals have been concluded.