Updated 11 April 2025
Date of assessment: 13 and 16 May 2025. We assessed the service due to some recent concerns raised regarding a lack of choice of bathing options, along with the length of time since our last rating inspection.
1 2 Flax Cottages is a care home for people with a learning disability. There were 9 people living at the home at the time of the inspection. The service constitutes two bungalows on one site, joined by an internal corridor.
The service was not always led in line with the principles and values that underpin Right Support, Right Care, Right Culture and other best practice guidance. This meant people living at the service were not always able to live as full a life as possible and achieve the best possible outcomes. The principles of Right Support, Right Care, Right Culture reflect the need for people with learning disabilities and/or autism to live meaningful lives that include control, choice, and independence. The provider had not always ensured this happened. The service consisted of 2 bungalows. It was registered to provide accommodation, care and support for up to 9 people. This is larger than current best practice guidance and the provider needed to do more to differentiate between the bungalows and to ensure people’s goals and social interests were treated individually, rather than as a group.
We gathered information from people who used the service, relatives, the acting manager, area manager, care staff and external professionals. We looked at all quality statements in the Safe, Effective, Caring, Responsive and Well-Led key questions.
At this assessment we found people did not always receive safe, person-centred care that was well managed.
Risks were not always comprehensively assessed and lacked person-centred detail regarding how to reduce risks at times. There were a range of environmental and infection prevention and control risks that had not been appropriately managed. The provider had contacted the relevant housing provider repeatedly, but still could have done more to ensure people had more dignified bathing spaces.
Leadership arrangements and governance had not always been clear, with delegation and champions only coming into place recently. Audits and other aspects of oversight had not identified some of the issues we found during inspection. We asked the provider to reflect on how the culture had deteriorated, and what they would do to ensure the culture became more goal-orientated and outward-looking.
We found the provider was in breach of legal regulations 9 (person-centred care), 12 (safe care and treatment) and 17 (good governance).
People interacted warmly with staff, who they clearly knew well. Staff likewise respected and valued their interactions with people and worked hard to ensure they felt safe and had their immediate needs met.
People who used the service, relatives, staff and external professionals all commented on the positive impact the acting manager and area manager had made, both in terms of addressing immediate areas of risk, and putting in place plans for longer term improvements to the culture.
There were sufficient staff to meet people’s needs safely, including when their needs changed. Staff were knowledgeable about people’s needs and individualities and generally worked well with visiting healthcare professionals and others to ensure people received consistent, joined-up care.
We have asked the provider for an action plan in response to the concerns found at this assessment.