Head Office

This was the first time we had inspected and rated this service. We rated it as requires improvement overall because improvements were required in relation to the safe and well led key questions. However, we did find that the service was effective, caring and responsive.

We rated the service as requires improvement because:

• The provider did not have a restraint reduction programme in place which is a national requirement for all services using physical interventions in response to disturbed behaviour by people with a learning disability and/or autism.
• The provider’s systems for training staff and monitoring compliance in relation to mental health legislation such as the Mental Capacity Act and the Mental Health Act were not fully embedded.
• Records did not always show how all agencies involved with an individual’s care had been involved in their care planning where this would have been appropriate.
• Notifiable incidents had not always been shared with CQC in accordance with regulatory requirements.
• The provider’s governance systems had not highlighted the issues we identified in relation to the care records and the lack of adequate safeguards in relation to the use of physical interventions.

However:

• Staffing levels on each shift enabled staff to give each young person the time they needed as teams were not short-staffed.
• Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment of young people’s needs and in collaboration with young people using the service and, where appropriate, their families and carers.
• The provider evaluated the quality of care they provided and made improvements on an ongoing basis.
• The teams included or had access to the full range of specialists required to meet the needs of the young people using the service. Managers ensured that these staff received adequate supervision and appraisal.
• Staff treated young people using the service with compassion and kindness, respected their privacy and dignity, and understood their individual needs. They actively involved young people using the service and, where appropriate, their families and carers in care decisions.
• The service was easy to access. The criteria for referral to the service did not exclude young people who would have benefitted from care and the service had no waiting list at the time of our inspection.