Aspire Hub 3

Not everyone using the service receives a regulated activity. The Care Quality Commission (CQC) only inspects services where a regulated activity is provided. This is help with tasks related to personal hygiene and eating. Where they do; we also consider any wider social care provided.

We assessed the service against the Right Support, Right Care, Right Culture guidance to determine whether the provider ensured that people with a learning disability and autistic people were treated with respect, equality, dignity, and given choices, independence, and access to local communities that most people take for granted. We found these principles were not consistently upheld, and further work was needed to improve the culture.

Although the registered manager had been in post for some time, the three service managers within the management structure were still relatively new to their roles. As a result, while governance systems in place had identified some improvement actions, not all required improvements had been identified, implemented or embedded into practice.

Audits carried out by the provider were not always effective. Governance and oversight arrangements were insufficient to ensure systems and processes were robust for assessing, monitoring, and improving the quality and safety of care. While improvements were underway with the introduction of a new digital system, more time was required to implement, embed and sustain a positive culture and effective management structure.

Information to support care and the administration of medicines was inconsistent and showed conflicting information in medication administration records (MARs), care plans, protocols for medicines that are taken ‘when required’ (PRN medicines), risk assessments and hospital passports. In some cases, the information documented was inaccurate, had insufficient detail or was no longer relevant. This meant there was a risk of people receiving their medicines incorrectly or inappropriate information being used to support their care which put them at risk of harm. The service has been responsive to the feedback we have shared, and leaders were taking remedial action to address the shortfalls we identified.

We identified breaches of regulation in relation to safe and effective treatment and good governance. We have asked the provider for an action plan in response to the concerns we found during this assessment.