Updated 29 February 2024
Date of assessment 12 March 2024 to 17 April 2024. The assessment was carried out in response to information of concern we received. We found four breaches of the legal regulations relating to person-centred care, safe care and treatment, governance and staffing. The provider still did not always support the delivery of high-quality person-centred care. Care records lacked detail due to inadequate recording. Gaps were identified in the recording of health records. However, staff knew the person well which meant the person developed skills. The provider still did not ensure safe care and treatment. The risk assessments did not include meaningful plans to minimise risks. Accidents and incidents were not effectively monitored. The provider informed us they had plans to address this. The provider had still not operated an effective system to assess, monitor and improve the quality and safety of care provided. Leaders were not fully aware of their responsibilities under the Mental Capacity Act 2005 (MCA). Systems were not effective in identifying or addressing areas for improvement. The provider informed us they had plans to address this. The provider had still not maintained oversight of staff meetings, supervisions, training and competencies. The provider informed us they had plans to address this. Since the last inspection, improvements had been made with management of medicines and recruitment procedures. We assessed against the Right Support, Right Care, Right Culture (RS, RC,RC) statutory guidance. We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.