De Bruce Court

This assessment was prompted in part by notifications of 2 incidents where people using the service were placed at serious risk of harm. These incidents are subject to further investigation by CQC to determine whether regulatory action is required. This assessment did not examine the specific circumstances of those incidents.

However, information shared with CQC identified potential concerns about how risks of falls from height were managed. We therefore looked at those risks as part of this assessment.

We found people were not always protected from avoidable harm. The provider had not always assessed, monitored or mitigated risks effectively, and governance systems had not ensured learning from incidents was identified, recorded and embedded. This resulted in breaches of Regulation 12, safe care and treatment, and Regulation 17, good governance.

We identified shortfalls in the safety of the premises, risk management, incident analysis and management oversight. Although the provider had taken some action to reduce risks, this was not always completed promptly or supported by effective systems to ensure risks were consistently managed.

We also found positive aspects of care. Staff were kind, worked well together and responded when people’s needs changed. Medicines, infection prevention and control and planned staffing levels were managed safely.

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 found the service was meeting the principles of Right support, right care, right culture. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it. The provider was working in line with this guidance.

At the time of our assessment, an interim manager was responsible for the day-to-day running of the service. They were supported by senior managers acting on behalf of the provider.