Aston House

We inspected this 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.

The inspection was prompted in part by notification of an incident following which a person using the service passed away. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of the incident.

However, the information shared with CQC about the incident indicated potential concerns about the management of risk. This assessment examined those risks. We found the provider was in breach of 5 legal regulations. These related to person-centred care, consent to care and treatment, safe care and treatment, good governance and staffing.

The service did not provide care which was safe, and risks were not being proactively identified and managed. Care records were contradictory, meaning information relating to the care people required was not always available for staff to follow. We identified a lack of effective monitoring and mitigation in relation to risks including arson, suicide, and fire safety. Guidance around the administration of medicines ‘when required’ and variable dose medicines was not accurate or detailed. Care plans and risk assessments were not always followed by staff.

Staffing levels were not always sufficient, and staff did not receive the training they required to provide a good service. The provider was not following the Mental Capacity Act 2005 when assessing people’s capacity and ability to make decisions. People were not always treated in a respectful and dignified way.

Governance and oversight were ineffective. There was an experienced acting manager in post who resigned following the first day of our inspection. Where audits were completed, we identified significant shortfalls in the quality of these audits, and they failed to identify the widespread and serious concerns we found. Where issues were identified, the provider did not always follow them up to ensure action was taken.

We sought immediate assurances from the provider to take action to significantly improve the service people were provided with. The provider was responsive and developed an action plan to address the improvements required.

This service is being placed in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we user our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.

In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/or appeals have been concluded.