Learning Disability Today
Supporting professionals working in learning disability and autism services

Failings uncovered at another Southern Health learning disability residential home

clipboardA Care Quality Commission (CQC) inspection of a Southern Health NHS Foundation Trust-run learning disability home has uncovered significant failings.

This inspection report, of 4 Piggy Lane in Bicester, was published days after an independent report had heavily criticised another Southern Health-run learning disability home for failing to prevent the death of 18-year-old Connor Sparrowhawk.

CQC inspectors found numerous failings at 4 Piggy Lane, which consists of two bungalows, each able to provide accommodation for five people with learning and physical disabilities, when they carried out their inspection on January 6 and 7. Of the 6 minimum standards assessed by inspectors, 4 Piggy Lane only a single standard. For the standard of assessing and monitoring the quality of service provision, enforcement action was taken, while the remainder required improvements.

Inspectors said they observed many episodes of good, personalised care and warm interactions by the care staff. But staff also told inspectors that they were not always able to deliver a high standard of care because of long-standing staffing problems, adding that they had far too much to do, which sometimes compromised the safety of the care they could deliver.

Following this, the inspectors checked the staff rosters for the previous 3 months, and the forthcoming month and found dates where staffing was either inadequate for the requirements of the people who lived there, or inappropriate for the continuing wellbeing of the staff.

In addition, care staff said they felt “badly managed” by the two on-site managers and “let down” by their employing authority, Southern Health.

Elsewhere, inspectors found insufficient processes in place for the safety of the people who lived there. For example, they were told of episodes of safeguarding concern, and but found no records for these incidents. The inspectors then alerted the local safeguarding team about these.

Another failing area the inspectors found was in medications policy. They found that one medication was out of date, and a lack of consistency in the way in which stock numbers were kept.


In response, director of social care for Southern Health, Phil Aubrey-Harris, said the trust found the outcome of the CQC report “unacceptable.”

He added: “We deeply regret that the quality of our social care service was not of the high standard our service users and their families should expect. We accept all of the report’s findings and have taken immediate action to address the problems highlighted by the CQC.”

Further reading: Death of 18-year-old with learning disabilities in assessment and treatment unit “was preventable”

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