Autism Plus – York and North Yorkshire was rated Requires Improvement overall following its first inspection at the new premises in November 2022, with a breach of Regulation 17 identified for failures in governance, record-keeping and medication management. Caring and Responsive were rated Good, reflecting kind, person-centred support from a stable staff team who knew people well.
Concerns (6)
critical
Record keeping
: “The provider failed to maintain accurate, complete and contemporaneous records in respect of each service user. Regulation 17(1)(2)(a)(b)(c)”
criticalGovernance: “The records and practices in place did not always provide evidence that all risks to people had been identified and that all regulatory requirements were being met.”
moderateMedication management: “Medicine administration records did not contain all of the expected information to ensure the medicines would be administered safely.”
moderateCare planning: “Care plans needed further development to ensure all risks had been considered and mitigated.”
moderateConsent / capacity: “People's capacity was not clearly defined, and records relating to best interest decisions were not detailed in the care records or accessible to staff if needed.”
minorCommunication with families: “Two others felt communication was less open, leaving them feeling unheard and disconnected.”
Strengths
· Staff knew people well and provided kind, compassionate care with positive and respectful language
· Sufficient staffing levels including one-to-one support where required, with robust recruitment and induction processes
· Strong safeguarding systems with clear reporting processes and senior management oversight of all safeguarding records
· Person-centred care plans focused on people's strengths, goals and aspirations promoting independence
· Good multi-agency working with positive feedback from independent professionals
Quality-Statement breakdown (24)
safe: Using medicines safelyRequires improvement
safe: Assessing risk, safety monitoring and management; Learning lessons when things go wrongRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Staffing and recruitmentGood
safe: Preventing and controlling infectionGood
effective: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawRequires improvement
effective: Staff support: induction, training, skills and experienceGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies to provide consistent, effective, timely care; Supporting people to live healthier livesGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesGood
responsive: Meeting people's communication needsGood
responsive: Supporting people to develop and maintain relationships and take part in activitiesGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Engaging and involving people using the service, the public and staffRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: How the provider understands and acts on the duty of candourGood
well-led: Continuous learning and improving careGood