Smitham Downs Road

We undertook this assessment to follow up on breaches of regulation identified at their previous assessment and review the previous rating of requires improvement. This assessment reviewed the quality statements in the key questions safe, effective and well-led.

The provider was previously in breach of the legal regulations in relation to safe care and treatment, need for consent and good governance. Improvements were found at this assessment, and the provider was no longer in breach of regulation.

We have 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.

Sufficient staff were in post to meet people’s needs. Staff received regular training to ensure they had the knowledge and skills to undertake their duties. Staff assessed risks to people’s safety and management plans were in place to mitigate those risks. Staff worked with the local authority safeguarding team to ensure any concerns were reported, investigated and learnt from. A safe and suitable environment was not always in place at the time of our assessment, however, a full refurbishment plan was in place and immediate risks were addressed on the day of our site visit. Action was taken to reiterate to staff the importance of adhering to safe infection prevention and control procedures, including the storage of mops and buckets. Improvements had been made to ensure safe medicines management.

Staff worked with other health and social care professionals to ensure people received continuity of care, and they were supported to maintain healthy lives. Staff implemented advice from healthcare specialists and supported people to have a healthy balanced diet in line with their needs. Staff adhered to the Mental Capacity Act 2005, including the Deprivation of Liberty Safeguards (DoLS). Improvements had been made to ensure DoLS authorisations were clearly reported to the CQC in line with the provider’s registration responsibilities.

There had been a high turnover of managers at the service, and the management and leadership of the service needed stabilising. A new permanent manager started on the day of our site visit and recruitment was in place to recruit a deputy and practice leads to further strengthen leadership at the service. Governance systems had improved and there was a regular programme of audit to review the quality and safety of service provision. Key service data was also collected and analysed to identify themes and implement learning.