Updated 19 November 2025
Dates of onsite assessment: 15 December 2025 and 16 December 2025.
The inspection was completed due to concerns around the quality of care at the home, prompted in part by notification of an incident following which a person using the service died. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of the incident. The service provides residential and nursing care for older people, including those living with dementia and people with complex health needs. At the time of our visit, 25 people were living at the home. The provider was under voluntary suspension with the local authority, and building works were ongoing to expand the service.
We identified significant concerns that could place people at risk of avoidable harm. The provider was in breach of 4 regulations relating to dignity and respect, safe care and treatment, premises and equipment and good governance.
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 found at this assessment.
Environmental risks were not consistently identified or addressed promptly, and infection prevention and control practices were poor. Audits and checks failed to detect hazards such as an unsecured cable, uncovered radiators, broken equipment and widespread cleanliness issues. These failings compromised people’s safety and wellbeing.
While we observed caring and responsive interactions from staff and noted some people felt safe and well cared for, these positive experiences were not consistent across the service. People living upstairs described an unpleasant environment with strong odours, limited meaningful activity and poor environmental upkeep, which did not support dignity or wellbeing. Records showed gaps in monitoring and care planning, including food and fluid charts, repositioning and stoma care, meaning staff were not always responding promptly or accurately to people’s physical needs.
Governance systems were ineffective. Audits did not identify serious risks, and medication oversight was weak, with expired competencies and incomplete medicine protocols. Leadership was reactive rather than proactive, addressing issues raised by external bodies but failing to learn and embed improvements across the service.
We found gaps in information and safeguarding. Policies displayed in communal areas were incomplete, and staff told us they would need to search online to find out how to report abuse. This meant people were not always given clear information about how to raise concerns.
The provider has begun taking action to address some concerns raised during the inspection.
Although staff were generally kind and familiar with people, significant concerns remain in relation to safety, infection prevention and control and governance. Improvements were needed to ensure people received care that is safe, dignified and person-centred.