Updated 22 February 2025
Date of assessment 10 March to 2 April 2025. The assessment was triggered by concerns received about the quality of the service.
This is a specialist service that is registered for use by autistic people or people with a learning disability. At the time of the assessment, the registered manager informed us that the service was not supporting anyone whose primary need and reason for support was related to their learning disability or autism. However, we assessed the care provision under Right Support, Right Care, Right Culture, as it is registered as a specialist service for this population group.
We found 3 breaches of the legal regulations in relation to safeguarding, safe care and treatment and governance. We have asked the provider for an action plan in response to the concerns found at this assessment.
The provider did not consistently protect people from abuse and improper treatment. We identified a safeguarding concern during the assessment. Staff did not always have appropriate guidance to enable them to provide care to meet people’s needs that was safe, supportive and in line with best practice. The governance of the service had failed to create a positive culture and staff morale was low. Staff did not feel involved, valued or listened to by management. Issues, concerns and complaints were not always robustly investigated to support effective learning.
There was not always a strong proactive and positive culture of safety within the service. The provider did not always report safety events. Whilst care calls were covered, staff were required to travel long distances and work long hours. There was a high staff turnover. Staff supervisions were not always meaningful and there were some shortfalls in staff training.
There were multiple medicine errors identified in audits. The provider had implemented new processes in an attempt to reduce these errors. The provider took some steps to support continuity of care across services. Some areas of people’s care plans contained a good level of information, and some professionals spoke positively about staff knowledge of people’s needs. The provider had introduced focus groups to try and involve staff more and improve morale. The registered manager was a member of a local external care group who met weekly to share knowledge, experiences and promote good practice. The provider had measures in place to gather feedback. Professionals told us communication with the service was good.