South Collingham Hall

Updated 11 June 2026

Dates of assessment: 16 June to 24 June 2026. This assessment was carried out due to concerns received around staffing and quality of care. South Collingham Hall is a care home which supports up to 33 people at the time of the assessment there were 15 people living at the home, some of whom lived with dementia.

We found significant failings in safety, leadership, governance, and oversight. Risks to people were not consistently identified, assessed, monitored, or mitigated, resulting in people being exposed to avoidable harm.

Care records, risk assessments, and care plans were often inconsistent, incomplete, or not updated to reflect people’s current needs. Safeguarding processes were ineffective, with some concerns not appropriately reported or escalated. The provider could not demonstrate that legal requirements relating to mental capacity, best interest decisions, and Deprivation of Liberty Safeguards (DoLS) had been consistently met.

Environmental and infection control risks were present, including trip hazards, strangulation risks, poor cleanliness, and damaged surfaces that could not be effectively cleaned. Staffing levels, particularly at night, were insufficient to meet people’s needs safely, and not all staff had received the training required to carry out their roles effectively.

Medicines were not always managed safely, with concerns relating to storage temperatures, PRN medication protocols, prescribed creams, and systems for monitoring the administration of time-critical medicines.

The provider lacked effective leadership, governance systems, and managerial oversight. Audits and quality assurance processes failed to identify serious concerns, meaning opportunities to improve care and safety were missed. There was no effective learning culture, and incidents, safeguarding concerns, and risks were not consistently reviewed, investigated, or used to drive improvements.

During the assessment, many of the concerns identified were fed back to the provider, who took immediate action to address some of the most significant risks. However, the overall findings demonstrated a service that required substantial improvement to ensure people received safe, effective, and well-led care.

We identified 3 breaches of regulation relating to safe care and treatment, safeguarding 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.

Updated 11 June 2026

Our observations showed people were supported by staff who were caring and knew people well. People experienced pleasant and calm mealtimes. People were offered drinks throughout. People were able to choose where they would like to have their meal.

Feedback from relatives was mixed, although most told us their family members were safe and generally well cared for by staff. One relative said, “Every time I phone everyone is very pleasant and friendly… Yes, [loved one] is safe,” while another told us, “In general they care for [loved one] well.”

Relatives described staff as kind, caring and knowledgeable about people's needs. Comments included, “They talk them through what they are doing and they know them well,” and “They don’t seem rushed when I've seen them.” Another relative felt staff knew their family member well, stating, “They do get [name],” when describing how staff understood the person's sense of humour.

People's representatives generally felt able to raise concerns. One relative said, “We make a point of raising concerns there and then,” although they also described poor communication following an incident, commenting, “It was upsetting. It was never fully explained what went on.”

Some concerns were raised about staffing levels. One relative told us, “Low staffing levels is a regular thing. When visiting sometimes there are no staff in the lounge at all,” and another said, “They could do with more staff, but that goes for all care homes.” Relatives also felt people could benefit from more meaningful activity and stimulation. Comments included, “There could be more things going on,” and “[Relative] sits a lot, does nothing. It's been a bug bear since day one really.”

Overall, relatives told us people were treated kindly and with dignity, but concerns remained regarding staffing levels, communication, opportunities for activity and stimulation, and the consistency of oversight within the service.