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“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, choices, independence and good access to local communities that most people take for granted.”

“We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgement about services providing support to people with a learning disability and autistic people. We considered this guidance as there were people using the service who have a learning disability and who are autistic. The service did not meet this guidance.”

“We found elements of care which was unsafe. There were concerns around risk management, restrictive practices, and staff training; particularly in relation to supporting people with complex health needs such as epilepsy. Some incidents had not been appropriately notified, and restrictive practices were in place without clear legal justification or best interest decisions having been recorded. These issues posed risks to people's safety and wellbeing and required urgent attention.”

“Inconsistencies in care delivery were also evident. People were not always treated as individuals, and there were disparities in how communication, independence, and meaningful activity were supported. Care plans lacked detail and accessibility, and did not consistently reflect people's goals, preferences, or aspirations. This limited people's ability to be involved in decisions about their care and reduced opportunities for promoting autonomy and wellbeing.”

“The application of the Mental Capacity Act was not in place, with missing assessments and restrictive practices not always considered in the context of best interests. Staff were not all equipped to communicate effectively with people, and in some cases, missed opportunities to engage meaningfully.”

“The provider had begun to take steps to improve governance, oversight, and learning from incidents. A weekly review process had been introduced to support better monitoring and promote a culture of safety. However, further work was needed to embed these systems and ensure they led to sustained improvements.”

“Overall, the provider failed to deliver safe, person-centred care, with widespread and serious concerns across governance, safeguarding, staff competency, and care planning. There was a fundamental lack of oversight, with governance systems failing to identify or respond to risks, including unsafe care practices, unregulated restrictive interventions, and breaches of legal requirements. Risk assessments were poor, incidents were not consistently reported, and staff lacked the training and support needed to meet people’s complex needs. Care plans were incomplete and did not reflect individuals’ preferences, aspirations, or rights, limiting people’s autonomy and wellbeing.”

“We found a breach in regulations for safe care and treatment, safeguarding, person centred care, need for consent, staffing and good governance. The provider did not ensure people were supported in the least…”