CQC Location ID:1-122938931
The assessment was carried out between 7 January 2026 and 26 January 2026. Withins (Breightmet) Limited is a residential care home providing personal care for up to 65 people in a purpose – built building over 3 floors. At the time of the assessment, the service was not supporting anyone with a learning disability or an autistic person. However, we assessed the care provision under Right Support, Right Care, Right Culture, as it is registered as a specialist service for this population group and has provided care to autistic people and people with a learning disability in the past. There were 2 breaches of regulation identified in relation to medication management and good governance. The provider did not manage medicines in line with best practice, and a breach of regulation was identified. The provider had breached regulations at the previous 3 inspections regarding medicines management. Key staff did not have the appropriate medicines training to be completing competency assessments with staff. Staff did not have advanced autism or learning disability training, despite them being registered to support people with these needs. The provider’s risk assessments and care plans lacked detail and were not person centred. There was a lack of evidence of how safety incidents had resulted in lessons learned. However, the provider did ensure safe transitions into the service. Staff assessed people’s needs, but these were not always being met or documented well. The provider did not have robust systems and processes regarding consent to care, including best interest decisions not being recorded. The provider ensured people could live as independently as reasonably possible, and they had choice and control over their care and treatment. However, consent processes needed improving. The provider did not ensure people’s care plans and risk assessments were person centred. However, the provider ensured people were all treated equally and had a good understanding of the types of discrimination they may face. The provider’s governance systems and processes were not robust, and a breach of regulation was identified. The provider did not always focus on continuous learning and improvement across the organisation. However, staff felt respected, supported and valued. Staff were clear on their roles and accountabilities, and the provider engaged well with people and the community to plan and manage the service. In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward. We have also asked the provider for an action plan in response to the concerns regarding good governance found at this assessment.
People and their relatives consistently told us they felt safe living at the service and described the care they received as excellent. People felt protected within their environment and confident that staff understood and managed risks appropriately. One relative told us, “Yes, [they] are very safe. Staff lift [them] and use the standee, [they] have a crash mat during the night, and staff don’t leave [them] alone when they are in a wheelchair.” People felt confident raising concerns with management if required. We saw examples where people or relatives had shared concerns and staff and leaders listened and took immediate action to address them. People and relatives told us the provider worked closely with them when they first moved into the service to develop personalised care plans and ensure their needs were fully understood. People spoke positively about how staff and leaders supported them to settle into the service. One person told us, “When I moved in at first, I didn’t know if I could sleep in a room on my own, but now, with support from staff, I feel safe and I love it here. I would recommend it to anyone.” When people were admitted to hospital, information was shared effectively to ensure hospital staff understood people’s needs and risks. People and relatives felt risks, including choking and falls, were well managed by skilled staff who knew people well. People and relatives told us there were good staffing levels and that staff were responsive. One person said, “I think they have a good quantity of staff; they are excellent at what they do.” People told us staff responded quickly to call bells and attended promptly. They also told us there was good consistency of staffing. One relative commented, “There are staff that have been here since my [relative] was in 11 years ago.” People were happy with the environment and the equipment available to them. They told us the service was clean, well maintained, and met their needs. Everyone we spoke with confirmed they received regular baths or showers and felt their personal care needs were met. People told us staff always asked for their consent before providing care and support. People did not feel restricted and said they were supported to make everyday choices. One person told us, “I decide what time I go to bed, if it is afternoon or evening, and when I want to go, they come and get me ready.” People and relatives described staff as kind, caring, and respectful of their dignity. People told us staff knew them well and listened to what mattered to them. They also spoke positively about the range of activities available. One person said, “There is always something going on, with karaoke and dancing every Tuesday and lots of seasonal celebrations.” People felt they were receiving value for money. People and relatives told us the home was well managed and that leaders listened to them. One relative told us, “Oh yes, the manager and [their] deputy listen. When [relative] first came in, I was in tears, and they sat me in the office to comfort me. They always keep me up to date with anything they are doing for [them].” Although people and relatives told us they had not attended residents’ meetings, they felt they were kept well informed and regularly updated by leaders within the service.