Date of assessment 16 December 2025 to 16 February 2026. The assessment was carried out in responseto CQC receiving information of concern. The service had made improvements and is no longer in breach of regulations. There were systems in place to safeguard people from abuse.The provider assessed and managed the risk of infection. The provider assessed and reviewed people’s care needs. The provider worked with professionals and relatives. People were treated with kindness, compassion and dignity. The provider cared about and promoted the wellbeing of their staff, and supported and enabled staff to always deliver person-centred care. However, the provider did not always make sure there were enough qualified, skilled and experienced staff. The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. The daily care notes did not always show staff obtained consent before carrying out personal care. We have assessed the service against ‘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.
PDF cached but not yet analysed by Claude; set ANTHROPIC_API_KEY and re-run npm run etl:reports -- --location 1-131464109.
Date of assessment 16 December 2025 to 16 February 2026. The assessment was carried out in response to CQC receiving information of concern. As a result of our assessment, we have rated the service requires improvement. We identified 3 continuing breaches of the regulations in relation to safe care and treatment, safeguarding and governance. We identified improvements had been made with the duty of candour recording and reporting statutory notifications to CQC. The provider did not consistently protect people from abuse and improper treatment, and staff were not always recruited safely. The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. There was a lack of governance oversight which meant the service did not have effective systems in place to monitor and improve the quality of the service. The provider assessed and managed the risk of infection. The provider assessed and reviewed people’s care needs and worked with professionals and relatives. People were treated with kindness, compassion and dignity. The provider cared about and promoted the wellbeing of their staff. We have assessed the service against ‘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 have asked the provider for an action plan in response to the concerns found at this assessment.
PDF cached but not yet analysed by Claude; set ANTHROPIC_API_KEY and re-run npm run etl:reports -- --location 1-131464109.
Chiltern Support and Housing was rated Requires Improvement overall following a focused inspection of Safe (Inadequate) and Well-led (Requires Improvement), with six regulatory breaches identified including safe care and treatment, safeguarding, consent, good governance, fit and proper persons employed, and duty of candour. Significant failures in medicines management, risk assessment, safeguarding responses, mental capacity compliance, and governance oversight placed people at risk of avoidable harm.
Concerns (15)
criticalMedication management: “PRN protocols could not be located...MAR record had been crossed through without signatures to confirm administration...medicines stored in three locations not subject to regular temperature monitoring.”
criticalSafeguarding: “One person's relative told us they had raised concerns in June 2022 regarding alleged unexplained injuries...no safeguarding referral had been made to the local authority. We raised a safeguarding alert.”
criticalCare planning: “One person's risk assessment in relation to their mobility included non-specific guidance...no specific care plan or risk assessment in place in relation to the person's PEG care.”
criticalGovernance: “Audits had been inconsistently completed and did not effectively drive improvements...Most progress comments were added on 31 January 2023 after the commencement of our inspection.”
criticalRecord keeping: “Care records were incomplete, not always up-to-date and did not consistently represent people's individual needs...confidential records stored in the dining area at one setting.”
criticalConsent / capacity: “Mental capacity assessments were not consistently completed in line with the Mental Capacity Act 2005...some best interests checklists had been completed after the assessor documented that the person had mental capacity.”
criticalInfection control: “Cleaning schedules were in place for toilets and bathrooms, however despite these being fully completed these areas were not cleaned to a satisfactory standard.”
criticalStaff competency: “Medicines competency records were not available for all staff...no evidence was available that staff were trained and competency assessed to assist with the nebuliser.”
criticalIncident learning: “The service had failed to submit notifications to CQC in line with requirements, including the failure to notify CQC of some instances of alleged abuse.”
criticalOther: “Staff recruitment practices were not always fully followed...CVs were routinely accepted...gaps in employment history were not consistently identified and explored.”
moderateStaffing levels: “Sometimes always short staffed, don't think we have enough staff on every shift…makes work more strenuous…for service users, think affects them too.”
moderateSupervision / appraisal: “Supervisions had not been conducted at frequencies in line with the provider's policy. Most supervision records reviewed contained minimal detail.”
moderateLeadership: “One registered manager demonstrated a lack of awareness about the frequency of incidents such as a person's seizures and struggled to locate routine paperwork during our visit.”
moderatePerson-centred care: “My son doesn't get any exercise...She is not really encouraged to try new things…as far as I can gather she has only been out with staff once in the last year.”
moderateCommunication with families: “Some relatives told us they had not received sufficient feedback when people had sustained injuries to help them understand how these injuries may have occurred.”
Strengths
· Positive feedback from professionals regarding timely and appropriate referrals and staff receptiveness to support.
· Some staff demonstrated strong knowledge of complex individual needs, including communication, behavioural and sensory requirements.
· The service worked with commissioning bodies to provide bespoke adapted environments for people with complex needs at short notice.
· Staff spoke about people with respect and kindness; people appeared comfortable in the presence of staff.
· Some people were supported to access meaningful activities including day centres, trips and holidays.
Quality-Statement breakdown (12)
safe: Using medicines safelyInadequate
safe: Assessing risk, safety monitoring and managementInadequate
safe: Learning lessons when things go wrongInadequate
safe: Preventing and controlling infectionInadequate
safe: Systems and processes to safeguard people from the risk of abuseInadequate
safe: Staffing and recruitmentRequires improvement
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Continuous learning and improving careRequires improvement