Updated 5 December 2025
We carried out an assessment of College House between 16 and 23 December 2025. This was a comprehensive assessment of all quality statements for this residential care home, which provides accommodation and personal care for up to 12 people, including autistic people or people with a learning disability. At the time of our assessment, 7 people were living at the service.
An assessment has been undertaken of a service that is used by autistic people or people with a learning disability. We have assessed the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence and good access to local communities that most people take for granted.
College House was previously rated good in all areas at its last inspection in 2017. Since then, we found the quality and safety of care had deteriorated significantly, and the service is not meeting several fundamental standards. We identified serious shortfalls in governance, risk management, and care planning, which placed people at risk of harm.
People told us they generally felt safe and staff were kind, but systems and oversight were ineffective. Environmental risks were not managed. We identified upstairs windows lacked tamper-proof restrictors, radiators were uncovered, and legionella checks were not completed in line with guidance. Medicines were not managed safely, for example: PRN (as required medicines) protocols were missing, and handwritten Medicine Administration Records (MAR) charts were not countersigned. Infection prevention and control was poor, with communal towels being used in bathrooms and gaps in cleaning records. Safeguarding processes were not robust—one safeguarding incident and a physical assault were not notified to CQC as required by law.
Care planning and risk assessments were incomplete and undated, making it unclear when reviews were due. There was no evidence of mental capacity assessments for people subject to a Deprivation of Liberty Safeguard (DoLS), and staff lacked understanding of the Mental Capacity Act 2005 (MCA) requirements. End-of-life care planning was inadequate: one person receiving end-of-life care was left without regular repositioning overnight, despite being doubly incontinent and at high risk of skin breakdown. Records showed gaps in monitoring and contradictory information about people’s needs.
We observed some kind and respectful interactions, and relatives told us staff were generally caring. However, we also saw examples of poor practice.
People’s bedrooms were personalised, and some people were supported to attend appointments and occasional outings. However, care plans did not show meaningful involvement of people or families, and aspirations were not reflected. Activities provision for people to enhance their well-being was inconsistent and unstructured.
Governance was weak. Audits for medicines, infection control, and daily notes were either not completed or lacked follow-up. The registered manager had not identified many of the shortfalls we found. There was no systematic approach to staffing levels or skill mix.
We have identified breaches of 7 legal regulations, including those relating to person centred care, consent, safeguarding, safe care and treatment, environment, good governance and staffing.
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.
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 provide 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.