Roy Kinnear House

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. The model of care and setting maximised people’s choice, control and independence. The home was small-scale and homely, in line with best practice guidance for learning disability services. Staff supported people to access community-based activities and religious services, and to maintain contact with loved ones. We saw staff use different methods of communication and adapt their approach based on people’s needs and preferences. People were involved in their daily routines and supported to express themselves in ways that suited them.

However, we found problems in governance, staffing arrangements, care planning, medicines management, and the oversight of health and safety processes. The lack of a registered manager for such a complex service also contributed to these failings. These issues affected the quality and consistency of care. For example, supervision records were not up to date, care plans and risk assessments were not consistently reviewed, health and safety audits had not been completed between January and April 2025, and the last recorded medicines audit was in December 2024, with some actions still outstanding at the time of our visit.

The provider had recently completed a quality audit and was in the process of developing an action plan to address these concerns. This gave us confidence that the service had recognised the areas requiring improvement and had begun taking steps to strengthen oversight and accountability.

Inconsistent staffing levels had also impacted service delivery. Some care plans and risk assessments were not reviewed or updated in line with people's changing needs. Activity planning was limited by staffing constraints, and records of care lacked structure and outcome-focused detail.

There were breaches of regulation relating to the management of medicines, care planning, infection prevention and control, and governance systems. We found shortfalls in how the provider ensured a safe environment, including missed health and safety checks, inconsistent cleaning practices, and a lack of infection control audits. Medicines were not managed safely, with issues such as excess stock, unclear protocols, and unresolved audit actions. Care planning documentation lacked clarity and consistency, and some care records had not been updated in response to people’s changing needs.

Staff demonstrated compassion and attentiveness in their interactions with people, and feedback from most families indicated that they were happy with the support provided. People appeared relaxed and at ease with staff. Staff showed understanding of people’s needs, used different forms of communication, and offered personalised support that took individual preferences into account. There was a clear focus on promoting dignity and respect in care delivery. Staff knew people well, and this helped foster trusting relationships.

Staff also spoke positively about their roles and expressed commitment to the people they supported. The provider had policies in place that promoted inclusion and equality and had begun implementing an electronic care planning system to improve consistency and person-centred documentation. People were supported in a culture that prioritised their rights and promoted positive outcomes.

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