Sturbridge

Sturbridge is a domiciliary care agency, providing personal care in people’s own homes. At the time of the assessment, they were supporting two people with regulated activity.

We assessed the service against ‘right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed autistic people and people with a learning disability respect, equality, dignity, choices, independence and good access to local communities that most people take for granted. The service was not working in line with the principles of right support, right care, right culture.

People were not consistently supported to have choice, control or meaningful involvement in their care, and important information about their needs, preferences and aspirations was not always captured in care plans. The guidance was not well understood by leaders, and this limited their ability to ensure care was person-centred, rights-based and delivered in a way that promoted independence and inclusion.

Relatives spoke positively about the service and consistently described warm, friendly and trusting relationships between staff and the people they supported. They told us staff approached care with kindness and understanding, which helped ensure people had positive daytoday experiences. People were supported by staff who knew them well, and feedback indicated that staff were responsive and attentive to people’s changing needs. However, significant gaps in documentation, risk assessment and governance affected the safety, consistency and oversight of the service. Care plans and risk assessments were not always complete, up to date or reflective of people’s needs, and important information about risks, preferences and health conditions was sometimes missing. This meant staff did not always have the written guidance they needed to provide consistent, person-centred care.

The absence of a registered manager had contributed to weakened oversight, inconsistencies in leadership understanding, and delays in addressing known issues. Although a governance audit identified some of the concerns raised during the assessment, improvements were not embedded, and the service lacked clear action plans to drive change.

Despite these shortfalls, we found no evidence that anyone had come to harm. Relatives felt reassured by staff’s commitment and the quality of day-to-day interactions. The management team were open to feedback and responsive when concerns were raised. A new, experienced manager was due to start shortly after the assessment period ended, which was expected to strengthen governance, oversight and leadership capacity.

We found two breaches of regulations. The service was in breach of the regulation relating to safe care and treatment, as gaps in risk assessment, care planning and oversight meant people were exposed to avoidable risk of harm. The service was also in breach of the regulation relating to good governance. Systems to assess, monitor and improve the quality and safety of the service were not effective, and leaders did not have sufficient oversight to ensure shortfalls were identified and addressed in a timely way. The service has been asked to complete an action plan detailing how these breaches will be addressed.