Sir Evelyn Road

Who the service is for

The service supports people with a learning disability and, autistic

KEY FINDINGS

We carried out this assessment on 20 July 2026. This service was previously rated as good. We carried out this assessment to confirm whether the good rating remains accurate. This report does not provide detailed information on areas where we found practice continues to meet a good standard. Instead, our findings focus on any areas where the service needs to improve or where we found exceptional practice.

The provider safeguarded people from abuse and avoidable harm and ensured staff understood how to recognise, report and escalate concerns. Staff felt confident raising concerns and learning from incidents to help keep people safe. One staff member said, "If I witnessed poor practice of a member of staff acting in a way that did not promote dignity, respect, privacy or safety, I would challenge the behaviour appropriately and report my concerns to the manager."

The provider assessed and managed risks to people's health, wellbeing and daily lives while supporting people to remain as independent as possible. One staff member explained, "Positive risk-taking is about enabling people to do the things that are important to them while putting suitable safeguards in place to keep them safe. We focus on what people can do rather than limiting opportunities unnecessarily."

The provider supported staff through training, supervision and ongoing development. One staff member said, "The staff team and management have been extremely supportive. Supervisions and ongoing support have helped me develop my confidence and understanding of the people we support."

The provider maintained a clean, safe and well-maintained environment that met people's individual needs. We observed sensory facilities and quiet spaces were available to support emotional wellbeing and reduce anxiety when needed. The provider also completed regular health and safety checks to ensure the environment remained safe and suitable.

The provider ensured people received their medicines safely and as prescribed by storing medicines securely, maintaining accurate records and following safe medicines management practices. One staff member stated, “When required (PRN) medication should never be administered routinely. I always refer to the individual's protocol and assess whether it is appropriate to give the medicine."

The provider worked closely with healthcare professionals, including psychologists, speech and language therapists, occupational therapists, physiotherapists and dietitians, to ensure people received care that reflected current guidance and specialist advice. Relatives told us they had seen positive improvements in people's wellbeing, confidence and involvement in meaningful activities.

The provider supported people to make decisions about their care and treatment wherever possible. Staff used communication boards, visual aids, social stories, photographs and Makaton to help people understand information and take part in decisions. During the assessment, we observed positive interactions between staff and people using the service.

Staff used personalised communication methods to help people make informed choices and remain involved in decisions about their care. One staff member said, "We support people to remain involved by using communication methods that suit their individual needs and help them make informed choices." Staff understood people's life histories, preferences, routines and goals and adapted support accordingly.

The provider involved people and those important to them in decisions about care and support. Families told us they felt listened to, involved and kept informed about important aspects of their relatives' care. Staff worked with families and healthcare professionals to reduce barriers and support positive outcomes.

The provider used governance and quality assurance systems to monitor the quality and safety of the service. Regular audits covered areas including medicines, incidents, care planning, health and safety, and outcomes for people. Leaders identified areas for improvement and acted when required.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that staff and management worked within the MCA. DoLS authorisations were appropriately applied for and overseen. People were not subject to unlawful or excessive restrictions and had choice, control and freedom over their lives.

The provider applied least restrictive approaches and adapted support to meet people's individual needs. Relatives spoke positively about the provider's approach to promoting people's rights while maintaining their safety. One relative commented, "The balance between safety and privacy has been considered appropriately."

The provider implemented safety measures, including support and agreed mealtime monitoring arrangements for people at risk of choking who preferred to eat in their bedroom, helping staff respond promptly if concerns arose. Other measures included falls monitoring equipment, door alarms, epilepsy monitoring devices and locked storage areas where choking risks had been identified. The provider completed decision-specific capacity assessments where required and considered people's ability to make decisions about their care and support.

We observed a staff member prioritised positive behaviour support and de-escalation techniques before using restrictive measures. When people became distressed, we observed staff offering reassurance, sensory support, music and access to quieter areas to help them regulate their emotions. One staff member stated, "Social stories help people understand situations, reduce anxiety and participate more confidently in their care."