Updated 27 May 2025
Date of Assessment: 24 July 2025 – 18 August 2025. The service is a residential care home providing support to 25 older people some of whom were living with dementia. We assessed the service to follow up on action we told the provider to take at the last inspection. At this assessment we found 1 new breach and 3 continued breaches of the legal regulations.
The provider was previously in breach of the legal regulation in relation to safe care and treatment and we had served a warning notice. There had been some improvement at this assessment, however, the provider remained in breach of this regulation.
The provider was previously in breach of legal regulation in relation to person-centred care. Improvements were not found at this assessment and the provider remained in breach of this regulation.
The provider was previously in breach of legal regulation in relation to good governance. Improvements were not found at this assessment and the provider remained in breach of this regulation.
At this assessment we found the provider was also in breach of the legal regulation in relation to safeguarding, specifically, paperwork and processes which were had not been completed correctly or organised effectively to evidence how people were supported in the least restrictive way when they were deprived of their liberty.
The provider did not always have a proactive and positive culture of safety. Lessons were not always learnt to continually identify and embed good practice. The provider did not share concerns quickly and appropriately. The provider had not always made referrals to the local authority when there were safeguarding concerns and the safety of people. There had been some improvement to how care plans were reviewed and updated on the provider’s electronic care planning system but we did not see evidence of how people, or their families, had been involved in these discussions. Management and organisation of care plans and supporting documentation was, in some cases, disorganised and ineffective. There were some examples where care was not delivered in line with people’s care plans. Improvements had been made to how the care environment was reviewed and monitored to ensure it was safe but there were still areas where further improvement was required. The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always work together well to provide safe care which met people’s individual needs. Management of medicines had improved following the previous inspection and the service was no longer in breach of regulations in relation to administration of medicines. The improvements which have already been put into place need to be sustained and embedded in to practice.
The provider did not always make sure people’s care and support were effective because they did not always check and discuss people’s health, care, wellbeing and communication needs with them. The provider did not plan and deliver people’s care and support with them, including what was important and mattered to them. Care and treatment was not always delivered in a way which was best practice or evidence based. Staff did not always support people to live healthier lives, or where possible, reduce their future needs for care and support. The provider did not tell people about their rights around consent or respect these when delivering care and treatment. The management team lacked understanding about the Deprivation of Liberty Safeguards (DoLS) and Mental Capacity Acts 2005 (MCA) paperwork and processes.
Members of staff were individually kind and caring when they interacted with people, However, they were task focussed and care was not person-centred and, sometimes, people’s privacy and dignity was not always respected. The provider did not treat people as individuals or make sure people’s care, support and treatment met people’s needs and preferences. The provider did not always promote people’s independence, so people did not always know their rights and have choice and control over their own care, treatment and wellbeing. The provider did not always care about and promote the wellbeing of their staff and they did not always support or enable staff to deliver person-centred care.
Care was not person-centred. The provider did not make sure people were at the centre of their care and treatment choices and they did not work in partnership with people, to decide how to respond to any relevant changes in people’s needs. There were significant shortfalls in how the provider understood the diverse health and care needs of people and their local communities, so care was not joined-up, flexible or supportive of choice and continuity. The provider did not make it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. People's care was not tailored to their individual needs and there was evidence of institutional approaches to care and support.
The provider did not understand the challenges and the needs of people and their communities. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity and openness. Leaders were not effective and not able to lead and manage the service effectively. The provider did not have clear responsibilities, roles, systems of accountability and good governance. Following the previous inspection of the service on 7 January 2025 there had been some improvements to some monitoring processes, specifically environment checks, but governance and management of the service was still failing overall. The lack of effective systems and management meant there was no drive to improve the quality of person-centred care and support being delivered. People continued to have poor experiences of care and there was a lack of action to improve outcomes for people.
This service is being placed in special measures. The purpose of special measures is to ensure services providing inadequate care make significant improvements. Special measures provides a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.
In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/or appeals have been concluded.
We have also asked the provider for an action plan in response to the concerns found at this assessment.