King Street - Care Home Physical Disabilities

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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

This means we looked for evidence that the provider met people’s needs.

At our last inspection we rated this key question outstanding. At this inspection the rating has changed to requires improvement. This meant people’s needs were not always met.

The service was in breach of legal regulation in relation to person centred care

This service scored 50 (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 make sure people were at the centre of their care and treatment choices and they did not always work in partnership with people, to decide how to respond to any relevant changes in people’s needs.

A new electronic care planning system had recently been implemented, and the interim management team were making improvements to people’s care records. However, there was a lack of meaningful collaboration with people and their relatives during this process and previous support planning had not been adequately reviewed. As a result, assumptions were made about individuals’ needs and preferences, leading to inconsistencies and outdated information within care plans. Staff were not always equipped with current guidance, which impacted their ability to deliver truly person-centred care. This meant people were at risk of not being supported in a way that met their preferences.

Throughout the inspection process we saw minimal person-centred care. A combination of poor staff deployment, a reliance on temporary staff who did not know people's needs well and inaccurate care plans meant people did not receive individualised support.

There were some shortfalls in how the provider understood the diverse health and care needs of people and their local communities, so care was not always joined-up, flexible or supportive of choice and continuity.

Care delivery was not always well coordinated or consistently person-centred. Transitions between staff shifts and external healthcare services lacked effective communication, which led to gaps in continuity and delays in meeting people’s needs. Care records were not routinely updated to reflect changes in individuals’ conditions or preferences, and staff did not always have access to current guidance. This impacted the quality and responsiveness of care, and reduced opportunities for people to experience seamless, integrated support.

A lack of cohesion between staff teams further contributed to fragmented care and had a negative impact on the experience and wellbeing of people supported. This reduced opportunities for individuals to receive seamless, integrated support tailored to their needs.

The provider did not always supply appropriate, accurate and up-to-date information in formats that were tailored to individual needs. We found some inconsistencies in care records and observations of staff practice. For example, one person with communication difficulties had a plan which stated they, communicate in writing. However, the person was communicating by using their finger to write on their leg. This suggested that their communication needs were not fully understood or supported.

Although face-to-face meetings were held with people using the service, there was a lack of follow-up communication in accessible formats, which limited people’s understanding and ability to stay informed. Relatives told us that recent communication had been poor, and they were not made aware of important changes to the service. This lack of timely and inclusive information impacted people’s ability to make informed choices and contributed to confusion and dissatisfaction with the care provided.

The provider did not always make it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. Staff did not always involve people in decisions about their care or tell them what had changed as a result.

Regular meetings were held to capture the views of people using the service. However, we reviewed meeting minutes between July 2025 and September 2025 and found concerns had been repeatedly raised by people using the service. These included long waiting times for support, unanswered call bells, staffing levels, and the high use of agency staff. Despite these issues being highlighted, there was no evidence of action taken to address or improve these concerns at the time of the inspection. Relatives also raised concerns regarding the lack of response to complaints. One relative told us, “Complaints aren’t dealt with, I have raised a few things, particularly about providing a better diet with more fresh fruit and vegetables, they are lucky to get an option of 5 a week. I know the chef also raised it, I haven’t seen an improvement and my relative continues to put on weight”. This lack of responsiveness undermined people’s confidence in being heard and contributed to ongoing dissatisfaction with the service.

The provider did not always make sure that people could access the care, support and treatment they needed when they needed it.

People did not consistently receive care and support in ways that reflected their individual circumstances, preferences, or protected characteristics. For example, individuals with higher support needs or limited mobility experienced barriers to accessing community activities due to staffing shortfalls and lack of transport. Some people told us they were unable to attend appointments or outings because drivers were unavailable, or staff were not deployed effectively. These issues contributed to unequal experiences and missed opportunities for inclusion, wellbeing, and personal development.

Staff and leaders did not always actively listen to information about people who are most likely to experience inequality in experience or outcomes. This meant people’s care was not always tailored in response to this.

While there were examples of good practice where barriers were removed such as supporting a person to travel by aeroplane and working with the local MP to improve wheelchair access to train services, these were not consistently replicated across the service. More recently, people had been negatively impacted by organisational changes, including a lack of stable leadership, limited access to transport, and ineffective staffing arrangements. In particular, staffing levels and deployment did not ensure that people who required staff to anticipate their care had access to support when needed. This contributed to unequal experiences and outcomes, especially for those with complex needs or higher levels of dependency.

People were not always supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

While some efforts had been made to support people’s long-term goals, there was limited evidence of structured planning that reflected individuals’ aspirations, changing needs, or preferences. People and their relatives were not consistently involved in future planning discussions, and care records lacked detail about how people wished to live their lives over time. Organisational instability, including changes in leadership and staffing, further impacted the service’s ability to deliver proactive and personalised future planning. This meant people were at risk of receiving care that was reactive rather than forward-looking.