Archived: College House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to inadequate.

This meant people were not safe and were at risk of avoidable harm.

The provider was in breach of legal regulation in relation to consent, safe care and treatment including manging medicines, safeguarding, environment, governance and staffing.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice.

While some staff understood safeguarding and said they would escalate concerns, we found examples where lessons were not learnt. For instance, an incident involving a physical assault in July 2025 was not raised as a safeguarding concern or notified to CQC. The registered manager told us they had completed an investigation, however, could not provide evidence of this. There was no clear oversight of audits or governance to ensure improvements were embedded.

This contributed to the breach of regulation in relation to safeguarding and governance.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care.

They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services. People were supported to attend hospital and GP appointments, and hospital passports were in use. However, care plans lacked detail and were not always updated, creating risks during transitions. Handovers were not consistently recorded; the last written handover was dated 16 November 2025.

Relatives told us communication about hospital admissions and incidents was poor, leaving them unaware of significant events. These gaps meant the service could not assure continuity of care during transitions.

This contributed to the breach of regulation in relation to governance.

A professional told us, “College House engages with our team to plan appropriate and timely equipment provision, environmental adaptations, and support needs, which helps promote safe transitions for the residents.”

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

Although staff could describe how they would escalate concerns, the registered manager failed to notify the local safeguarding team and CQC of safeguarding incidents and did not keep investigation records. There was no evidence of systematic oversight or lessons learned from safeguarding events. These gaps compromised people’s right to live safely and free from harm. We advised the registered manager to raise 2 safeguarding concerns in relation to physical abuse and organisational abuse. Although the registered manager completed these referrals, there was a delay.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found the service had applied for a DoLS to the correct legal authority, however was not working in line with the principles of the Mental Capacity Act 2005. There was no evidence of mental capacity assessments for people subject to DoLS.

This contributed to the breach of regulation in relation to safeguarding and consent.

People told us they felt safe, and relatives said staff were kind, but governance failures placed people at risk.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People were not consistently involved in managing risks. Risk assessments were incomplete or missing for key hazards such as window restrictors, radiators, and kettles. People’s care plans lacked personalised strategies in relations to risks associated with epilepsy, diabetes or skin integrity. For example, 1 person at the end of their life required regular repositioning to reduce the risk of skin breakdown or the development of a pressure ulcer, but was left overnight without checks, and their care plan did not reflect this need. This meant people were at risk and the provider did not do all that was reasonably practicable to mitigate these risks.

This contributed to the breach of regulation in relation to safe care and treatment.

Relatives told us they wanted better involvement in care planning.

Staff said they knew people well and supported them to make choices day-to-day, but records did not evidence this.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

The environment posed avoidable risks. For example, upstairs windows lacked tamper-proof restrictors, posing a risk of falls. Radiators were uncovered with no risk assessments in relation to burns and legionella checks were not completed, increasing the risk of harm from legionella- based contamination. We discussed this with the registered manager, who was not aware of the Health and Safety Executive guidance ‘Health and safety in care homes’ published in 2014, which identifies action required to assess, mitigate and manage risk to ensure the premises is suitable and properly maintained. We discussed these concerns with the registered manager and advised them to take action to minimise the risk of harm.

Fire drills and risk assessments were in place, but emergency lighting checks were overdue.

These shortfalls meant the provider could not be assured the premises was consistently safe. This contributed to the breach of regulation in relation to safe care and treatment and safe environments.

Relatives described the home as “warm” but noted it was “a little run down.”

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

Staffing levels did not always meet basic care needs and did not allow people to go out as often as planned. Staff and relatives said outings were limited because one person required 2 staff members to support them, with only 2 staff being rostered on shift 24/7 for the whole of the service. Throughout the night there were 2 staff on shift, between 11pm and 7am, these members of staff were asleep. The registered manager and staff told us they would wake if a person used their call bell. However, throughout our assessment, there was 1 person who could not use their call bell or gain staff attention when needing support. This person required regular repositioning, and staff were not meeting this person’s needs.

The registered manager told us there was no systematic approach to rotas to ensure people were always supported with care and treatment. On occasions, staff without appropriate training were rostered, for example at times there were no staff within the service with end-of-life care or food hygiene training. This placed people at risk of poor care outcomes.

This contributed to the breach of regulation in relation to staffing and good governance.

Staff told us they worked well together and were committed to people’s care, but governance of staffing was weak.

Safe recruitment practices were being followed. Staff had references and Disclosure and Barring service (DBS) checks, as required. DBS checks provide information, including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Infection control measures were not fully effective. While Personal Protective Equipment (PPE) was available and audits were completed, communal towels were used in bathrooms, and paper towels were missing, this was not in line with nationally recognised published best practice. Cleaning schedules were poorly maintained, and we found gaps in kitchen cleaning and temperature records. These practices increase the risk of cross-contamination exposing people to harm.

We observed areas within the service were dirty. For example, dining room tables and areas within the service were smelling damp and had visible mould.

Staff had some Infection Prevention Control training, but not all were up to date.

The service had a cleaner, however this was not daily. One staff member told us, “I think the building is of its time and the interior design of it all could be improved, we do have a cleaner that keeps it all clean as best as they can”.

This contributed to the breach of regulation in relation to safe environment.

The provider did not always make sure medicines and treatments were safe and met people’s needs, capacities and preferences.

Medicine Administration Records (MAR) charts had missing signatures, handwritten entries were not countersigned, and PRN (when required) protocols were absent or inaccessible. Controlled drugs were not always double-signed by trained staff as required. The provider could not be assured their practise was in line with National Institute for Health and Care Excellence (NICE) guidance for managing medicines in care homes. This meant the provider could not always be assured staff were following national guidance and people were receiving their medicines in line with the prescribers instructions, placing them at risk.

Staff undertook weekly medicines audits. Records were last completed in May 2025. However, these audits were ineffective and failed to identify the concerns found during this assessment. Medicines care plans were outdated and lacked detail about risks and how best to support a person with administration methods. The provider did not have a ‘Stopping over medication of people with a learning disability and autistic people’ (STOMP) policy or relevant information within their medication policy, and staff competencies were not regularly reviewed. Stopping over medication of people with a learning disability and autistic people (STOMP) is a national NHS England work programme to stop the inappropriate prescribing of psychotropic medications.

This contributed to the breach of regulation in relation to safe care and treatment and governance.

We observed staff administering medicines to people with care and in a person-centred way.

Relatives felt assured medicines were managed safely, but records did not support this.