The assessment was undertaken between 20 May 2025 and 19 June 2025. The Cube Disability Ltd. is a domiciliary care agency providing personal care during short breaks to people living with a learning disability or autistic people who usually attend their day centres. The service only provided personal care during these short breaks. At the time of our assessment there were only two2 people receiving personal care and this had been provided at accessible holiday accommodation in the UK. The service had also run other holidays prior to the assessment, including to Disneyland Paris. The assessment was carried out remotely. This assessment was carried out to follow up from our previous assessment to consider whether improvements had been made. We assessed a total of 33 quality statements. At the last assessment this location was rated requires improvement. During this assessment we found that the location had made improvements and were no longer in breach of one of the legal regulations in relation to governance. They had a robust system of audits and management oversight in place that had identified the minor issues seen during the inspection and had put plans in place to address these. People had care plans and risk assessments that were tailored to meet their needs and keep them safe. They had chosen the holidays they wanted to go on and the activities they wanted to do. Medicines management had improved and there were protocols in place for people who required ‘as needed’ medicines. The overall rating of this service has improved to good. 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. We found that the service had provided support in line with this guidance. People were supported to be part of their communities and were empowered to make decisions about the activities they wanted to take part in.
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Date of assessment 8 May to 11 July 2024. The Cube Disability Ltd. is a domiciliary care agency providing personal care during short breaks to people living with a learning disability or autism who usually attend their day centres. At the time of our assessment there were 37 people using the short breaks service, however, only 2 people received personal care. As part of our assessment activity, we undertook on-site visits on 24 June and 11 July 2024. This assessment was carried out to follow up from our previous inspection to assess them for improvements. We assessed a total of 25 quality statements. At the last inspection, this location was rated requires improvement. During this assessment, we found concerns with the quality of the oversight of people’s care. We identified a continued breach of one of the legal regulations in relation to governance. The overall rating of this service has remained requires improvement. 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.
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The Cube Disability Ltd, a domiciliary holiday-care agency for people with learning disabilities and autism, was rated Requires Improvement overall at its first inspection in July 2023, with Warning Notices issued for breaches of Regulations 12 and 17 relating to unsafe medicines management, absent risk assessments and care plans, and inadequate governance systems. Caring was rated Good, reflecting strong, compassionate relationships between staff and people, though systemic failures in consent, staff training and record-keeping placed people at risk of harm.
Concerns (13)
criticalMedication management: “People's MAR charts did not indicate what the medicines were prescribed for, the side effects experienced by people and the times the medicines were due.”
criticalMedication management: “The provider failed to have a system to monitor the safety of the medicines management; they failed to identify the missing information or potential medicines errors.”
criticalCare planning: “People did not have care plans or behavioural support plans for staff to refer to. Staff did not have the information they needed to always know how to provide safe care.”
criticalConsent / capacity: “The provider did not have systems in place to ensure all mental capacity assessments had been recorded, or systems to arrange for best interest decisions.”
criticalStaff training: “Not all staff had received training and refresher training in medicines management, catheter care and epilepsy.”
criticalGovernance: “The provider failed to have adequate systems to assess, monitor and mitigate the risks of people's health, safety and personal care needs. This was a breach of regulation 17 (2).”
moderateRecord keeping: “Staff did not record daily notes to demonstrate people received their care as planned.”
moderateStaff training: “Not all staff had received training or refresher training in first aid, fire safety, challenging behaviour, control of substances hazardous to health, safeguarding, moving and handling.”
moderatePerson-centred care: “People's protected characteristics under the Equality Act 2010 including age, disability, gender reassignment and religion had not been recorded.”
moderatePerson-centred care: “The provider failed to have systems to provide accessible information to support people to understand and be involved in the planning of their holidays.”
moderateStaffing levels: “There was no system to calculate the number of staff required on each holiday. There was no provision for staff breaks or contingency for managing people's care.”
moderateIncident learning: “There were not enough systems in place to record and analyse the planning, risk assessment and outcome of the care received by people during their holidays.”
moderateCommunication with families: “People's communication needs were not recorded; staff and emergency services did not have all the information they needed to communicate effectively with people.”
Strengths
· Staff knew people well from day centres and showed kindness, dignity and respect in their interactions.
· Relatives praised staff warmly: '[Staff] just get [Name]. They understand [Name] so well' and '[Staff] are honestly amazing.'
· People were involved in choosing holiday types and activities; staff adapted activities to ensure full participation including for wheelchair users.
· Safe recruitment practices including DBS checks were carried out and the provider understood its duty of candour.
· The provider had sought feedback via surveys and used it to drive service improvements.
Quality-Statement breakdown (22)
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Using medicines safelyRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongRequires improvement
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 law
Requires improvement
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Supporting people to eat and drink enough to maintain a balanced dietRequires improvement
effective: Staff working with other agencies; supporting people to live healthier lives and access healthcareRequires improvement
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 preferencesRequires improvement
responsive: Meeting people's communication needsRequires improvement
responsive: Supporting people to develop and maintain relationships; support to follow interests and activitiesGood
responsive: Improving care quality in response to complaints or concernsGood
well-led: Managers and staff being clear about their roles; continuous learning and improving careRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringRequires improvement
well-led: Engaging and involving people using the service, the public and staffGood
well-led: How the provider understands and acts on the duty of candourGood