Home / Sources / CQC / Affinity Trust Specialist Support Division North
Index live
Source · CQC inspection

Affinity Trust Specialist Support Division North

Type Social Care Org Region Yorkshire & Humberside Last inspected 13 Apr 2022

Overall rating: Inadequate  View full CQC report

Domain ratings

Five CQC key questions
Safe
Inadequate
Effective
Requires Improvement
Caring
Requires Improvement
Responsive
Requires Improvement
Well-led
Inadequate

Earlier inspection findings

pre-2024 framework · 8 must-do 5 should-do

Must-do actions (8)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 8
Must do
Effective
The service was not working within the principles of the MCA
Regulation: Regulation 9 HSCA RA Regulations 2014 Person-centred care
⚠ There was no evidence the least restricted option was considered. There was no mental capacity assessments or best interest decisions completed. People were not always given choice about how they liked their care and treatment to be given.
Must-do action 2 of 8
Must do
Safe
The provider had failed to ensure risk assessments were completed in relation to the provision of people's care and health and safety checks.
Regulation: Regulation 12 HSCA RA Regulations 2014 Safe care and treatment
⚠ Risk assessments to identify and protect people's health needs were lacking. This resulted in an instance of a person requiring hospital admission. There was a record of accidents and incidents. However, the provider was unable to evidence how they mitigated related risk identified following analysis of these records. Fire safety …
Must-do action 3 of 8
Must do
Safe
The provider failed to safely manage medicines.
Regulation: Regulation 12 HSCA RA Regulations 2014 Safe care and treatment
⚠ Medicines were not managed safely. This CQC inspection and two previous inspections by the Clinical Commissioning Group (CCG) identified medicine files containing information regarding discontinued medicines. This inspection also identified discrepancies in medicine doses given. Medicines were not stored safely in individual locked safes, however, they were not stored in …
Must-do action 4 of 8
Must do
Safe
The provider had failed to ensure there were robust safeguarding systems in place.
Regulation: Regulation 13 HSCA RA Regulations 2014 Safeguarding service users from abuse and improper treatment
⚠ Safeguarding systems were not established. At one of the locations there was ongoing safeguarding issues and the leadership were not able to clearly evidence how these were being managed. We were not assured all safeguarding concerns were raised. Not all staff were up to date with safeguarding training.
Must-do action 5 of 8
Must do
Well-led
The provider had failed to ensure they assessed, documented and monitored quality assurance checks.
Regulation: Regulation 17 HSCA RA Regulations 2014 Good governance
⚠ Leadership was inconsistent and there was a lack of managerial oversight. Information which should have been readily available was not accessible or shared with us in a timely manner. There were significant gaps in records; these included gaps in medication records, people's communication plans and activity plans. The Internal audit …
Must-do action 6 of 8
Must do
Effective
The provider had failed to ensure monitor and consider information related to hydration and nutrition.
Regulation: Regulation 12 Safe care and treatment of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
⚠ The provider did not recognise the risk of reduced fluid intake. People were not supported to drink enough fluid and there was not enough evidence to show people were supported with accessing or encouraging fluid intake. The consideration of people's health needs was not evidenced with meal planning.
Must-do action 7 of 8
Must do
Responsive
People's needs and any changes in their care and support was not always shared with staff.
Regulation: Regulation 9 Person-centred care of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
Must-do action 8 of 8
Must do
Well-led
The provider had failed to ensure learning was used to inform improvements associated with risk and the provision of people care.
Regulation: Regulation 17 Good governance of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
⚠ The provider audited the service on a periodic basis, to help share learning, ensure standards and identify trends. However, the audits were not robust, learning and trends were not reliable. For example, the key quality audits were not detailed, and actions did not have a review date. The service improvement …

Should-do actions (5)

Recommended improvements to enhance service quality.

Should-do action 1 of 5
Should do
Effective
The provider reviews staff supervision, compliance with training and takes action to update their practice accordingly.
Should-do action 2 of 5
Should do
Well-led
The provider uses feedback from staff, people and relatives to inform improvement within the service.
Should-do action 3 of 5
Should do
Safe
The provider to immediately review and act on their current practice regarding risk management.
Should-do action 4 of 5
Should do
Safe
The provider to immediately review and update the documentation.
Should-do action 5 of 5
Should do
Effective
The provider to immediately review their practice and act accordingly.

Location details

CQC ID: 1-10809280786
Local authority: Kirklees
Region: Yorkshire & Humberside

Inspection report

Type: Inspection report
Date: 13 April 2022
Rating: Inadequate
Actions: 8 must-do 5 should-do
AI-extracted 17 Feb 2026