We carried out this inspection from 6 January 2026 to 26 January 2026. The service is a supported living service, providing support to people within their own homes, including people requiring support with their mental health, people with a learning disability and autistic people. There were 22 people in receipt of a regulated activity at the time of the inspection. The Care Quality Commission (CQC) only inspects where people receive personal care. This means help with tasks related to personal hygiene and eating. Where they do, we also consider any wider social care provided. We assessed this service due to receiving information of concern. We inspected 33 quality statements. This service had previously been rated requires improvement. We found 2 breaches of regulations in relation to person-centred care and governance. People’s assessed needs were not always managed safely. People were not always supported to eat healthily and were not always engaged in meaningful activities. Medicines were not always managed safely. The provider’s internal monitoring systems failed to identify all of the concerns we found during this inspection and robust action had therefore not been taken to make improvements. The registered manager and provider were motivated to improve the service and started addressing these shortfalls during the inspection. People were supported to have choice and control in some areas, could give feedback on their care, and were supported by staff who knew them well and treated them with kindness and respect. Staff were recruited safely and received appropriate training and supervision. Staff were trained to respond and raise safeguarding concerns both internally and to external agencies. The service learned from incidents and action was taken to ensure improvements were made where needed. We 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, choice, independence, and good access to local communities which most people take for granted. We found people did not always receive care and support in accordance with the principles of this guidance.
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First inspection of this supported living service rated Requires Improvement overall, with breaches of Regulation 17 (good governance/record keeping) and Regulation 18 (staffing/training) identified. Caring and responsive domains were rated Good, with concerns centring on staff training gaps, MAR chart inaccuracies, and ineffective quality assurance oversight.
Concerns (10)
criticalStaff training: “Staff did not receive appropriate support and training to carry out their duties safely. This placed people at risk of receiving inappropriate or unsafe care.”
criticalRecord keeping: “there were failures to record, monitor and improve the quality and safety of the service, failure to maintain accurate records was a breach of regulation 17”
moderateMedication management: “Medication administration record (MAR) information supplied to us had gaps that the provider was unable to provide evidence of.”
moderateGovernance: “The provider's systems and quality assurance processes were not effective at supporting robust oversight of the safety and quality of people's care.”
moderateStaff competency: “There was not a robust effective system in place to ensure that the provider employed people who were suitably qualified, competent and experienced.”
moderateSupervision / appraisal: “Staff supervision and support was inconsistent and did not meet the needs of all staff.”
moderateSafeguarding: “not all staff we spoke to knew how to access the policies on safeguarding or whistleblowing. This meant that not all staff were aware of the policies to keep people safe from abuse.”
moderateIncident learning: “debriefs did not always happen in a timely manner or have evidence of being followed up.”
minorComplaints handling: “The provider did not supply us with their complaints policy, and we were unable to see any recording of complaints made to the provider.”
minorStaffing levels: “We are not too happy about the amount of agency staff. It's difficult to staff adequately.”
Strengths
· Care focused on people's abilities and promoted their independence, with people having choice and control around care arrangements.
· Staff used accessible communication methods including Makaton, PECS and social stories tailored to individual needs.
· Care plans followed positive behavioural support principles with detailed individual risk assessments.
· Provider worked well with external stakeholders and professionals such as occupational therapists and the intensive support team.
· Good understanding and application of the Mental Capacity Act 2005 principles.
Quality-Statement breakdown (26)
safe: Assessing risk, safety monitoring and managementNot rated
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Staffing and recruitmentNot rated
safe: Using medicines safelyNot rated
safe: Preventing and controlling infectionNot rated
safe: Learning lessons when things go wrongNot rated
effective: Staff support: induction, training, skills and experienceNot rated
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the law
Not rated
effective: Supporting people to eat and drink enough to maintain a balanced dietNot rated
effective: Staff working with other agencies to provide consistent, effective, timely careNot rated
effective: Supporting people to live healthier lives, access healthcare services and supportNot rated
effective: Ensuring consent to care and treatment in line with law and guidanceNot rated
caring: Ensuring people are well treated and supported; respecting equality and diversityNot rated
caring: Supporting people to express their views and be involved in making decisions about their careNot rated
caring: Respecting and promoting people's privacy, dignity and independenceNot rated
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesNot rated
responsive: Meeting people's communication needsNot rated
responsive: Supporting people to develop and maintain relationships to avoid social isolationNot rated
responsive: Improving care quality in response to complaints or concernsNot rated
responsive: End of life care and supportNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsNot rated
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringNot rated
well-led: Engaging and involving people using the service, the public and staffNot rated
well-led: Continuous learning and improving careNot rated
well-led: How the provider understands and acts on the duty of candourNot rated
well-led: Working in partnership with othersNot rated