Withins (Breightmet) Limited

At the time of the assessment, the service was not supporting anyone with a learning disability or an autistic person. However, we assessed the care provision under Right Support, Right Care, Right Culture, as it is registered as a specialist service for this population group and has provided care to autistic people and people with a learning disability in the past.

There were 2 breaches of regulation identified in relation to medication management and good governance.

The provider did not manage medicines in line with best practice, and a breach of regulation was identified. The provider had breached regulations at the previous 3 inspections regarding medicines management. Key staff did not have the appropriate medicines training to be completing competency assessments with staff. Staff did not have advanced autism or learning disability training, despite them being registered to support people with these needs. The provider’s risk assessments and care plans lacked detail and were not person centred. There was a lack of evidence of how safety incidents had resulted in lessons learned. However, the provider did ensure safe transitions into the service.

Staff assessed people’s needs, but these were not always being met or documented well. The provider did not have robust systems and processes regarding consent to care, including best interest decisions not being recorded.

The provider ensured people could live as independently as reasonably possible, and they had choice and control over their care and treatment. However, consent processes needed improving.

The provider did not ensure people’s care plans and risk assessments were person centred. However, the provider ensured people were all treated equally and had a good understanding of the types of discrimination they may face.

The provider’s governance systems and processes were not robust, and a breach of regulation was identified. The provider did not always focus on continuous learning and improvement across the organisation. However, staff felt respected, supported and valued. Staff were clear on their roles and accountabilities, and the provider engaged well with people and the community to plan and manage the service.

In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.

We have also asked the provider for an action plan in response to the concerns regarding good governance found at this assessment.