During an assessment under our new approach
The assessment was carried out between 8 April 2026 – 24 April 2026. We visited the home on the 8 April 2026 and reviewed information the registered manager and provider sent us electronically following our visit. We carried out this assessment following information received by CQC relating to safeguarding matters and concerns about the management of the service.
Ravenstone Care and Rehabilitation Home is a care home providing personal care to up to 14 people. At the time of our assessment, there were 13 people living at the service, including people living with dementia, mental health conditions, and 2 people who had a learning disability. Only 5 people were receiving support with personal care and therefore came within the scope of the CQC‑regulated service. The remaining people did not receive personal care; instead, they were supported with accommodation and social support, which are not regulated activities. As a result, our assessment focused on the experiences and outcomes of people receiving personal care under the regulated service.
The home was not registered as a specialist service for people with autism or a learning disability. There were 2 people living at the home who had a learning disability, however, they did not receive personal care and therefore did not fall within the scope of the regulated activity.
While we were not assessing the care provided to these individuals, we would still expect the registered manager to have an awareness of relevant national guidance. The registered manager was not aware of the guidance ‘Right Support, Right Care, Right Culture’, which sets out expected standards to ensure that people with a learning disability and autistic people are treated with dignity and respect, experience equality, and are supported to have choice, independence, and meaningful access to their local communities. As the registered manager was not aware of this guidance, the service had not been mapped against these principles.
We found 4 breaches of the legal regulations relating to safe care and treatment, safeguarding people from abuse and improper treatment, duty of candour and governance.
Systems to safeguard people and manage risks were not effective. Required safeguarding notifications had not been submitted to the CQC, which limited external oversight of risks to people.
There were shortfalls with the environment. Fire safety checks, drills and training had not been completed as planned and fire doors were not always suitable. In addition, routine health and safety checks, such as water temperature monitoring had not been carried out as planned.
Equipment and environmental adaptations intended to promote independence were not always identified, in place, or reviewed. This included gaps in the provision of appropriate support equipment, such as aids to support safe mobility and reduce the risk of falls.
Accidents and incidents were not analysed to identify trends, themes, or repeated risks, and opportunities to reduce the risk of recurrence were missed. In addition, records did not demonstrate that duty of candour requirements had been met, as there was limited documented evidence of appropriate apologies, follow‑up actions, investigations, or lessons learned following safety incidents.
Care plans and risk assessments did not detail the actions being taken to manage identified risks. This included a lack of recorded actions to reduce people’s risk of accessing stairs, supporting people safely in relation to their behaviours and responding to weight loss. As a result, staff did not always have clear guidance to follow, which increased the risk of inconsistent care and meant people were potentially exposed to avoidable harm. In addition, an effective system was not fully in place to ensure medicines were managed safely and in line with best practice.
Although a staffing tool was in place, this was based on dependency levels and allocated care hours and did not take account of additional duties staff were required to undertake, such as cooking and kitchen responsibilities. As a result, staff were frequently required to move between roles, which affected the continuity and coordination of care.
Training and staff meetings had not always been undertaken as planned. While staff told us they felt supported, systems to enable, develop, and sustain safe and consistent practice were not reliably effective.
Governance arrangements did not provide effective oversight or assurance. There was no evidence of provider-level monitoring, and records were not consistently maintained to demonstrate how risks were identified, performance reviewed, or improvements implemented and sustained. As a result, leaders were unable to demonstrate that systems were effective in driving and maintaining improvements in care and outcomes for people.
Despite the shortfalls identified above, staff spoke very positively about working at the home and the support they received from the registered manager and the staff team. One staff member told us, “The manager is approachable and if anything is needed she will get it. It is a happy environment to work in and everybody gets on with each other.”
The service liaised with external professionals, including district nurses, social workers, paramedics, GPs and the mental health team. We received positive feedback from a health and social care professional who told us the service engaged well them and brought appropriate referrals and concerns to their attention.
Following our assessment, the registered manager told us that additional staff, including a maintenance staff member and a cook were in the process of being recruited. They also told us that activities provision had increased and was now available 3 days a week. A range of training was being organised and undertaken to further support staff development and improve practice. They said a hoist had been purchased, along with additional aids and adaptations, to better meet people’s mobility and support needs. In addition, support had been provided to help staff use the electronic care management system more effectively, to ensure people’s goals and outcomes were appropriately recorded, planned, delivered, and reviewed.
We have asked the provider for an action plan in response to the concerns found at this assessment.
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.