- Care home
Sands Lodge
We served three warning notices on R G Care Ltd on 21 August 2026 for failing to meet the regulation related to Good Governance (Reg 17), Safe Care and Treatment (Reg 12) and Need for Consent (Reg 11) at Sand Lodge.
Assessment report published 1 October 2026
Contents
Ratings
Our view of the service
Date of Inspection 29 July 2026 to 09 September 2026.
This comprehensive assessment included feedback from people, relatives, staff and professionals, alongside observations of care and a review of records.
Sands Lodge provides accommodation and personal care for people with a learning disability and autistic people and also people with mental health needs. The service is registered to provide care for up to 18 people. As part of our assessment, we considered the Care Quality Commission (CQC) guidance Right support, right care, right culture that underpins our approach to assessing services for autistic people and people with a learning disability.
At the previous assessment the service was rated Good. Following this assessment, the rating has changed to Requires Improvement. We identified breaches of regulations 10, 11, 12, 17 and 19 relating to dignity and respect, consent, safe care and treatment, good governance and fit and proper persons employed.
Improvements were needed to ensure people consistently received care that promoted their rights, privacy, dignity, choice and control. Care planning and risk assessments did not always accurately reflect people's current needs or provide sufficient guidance to staff. The provider did not always follow the principles of the Mental Capacity Act 2005 and informed consent was not always appropriately assessed, recorded or reviewed. We also identified environmental risks that had not been adequately assessed or mitigated.
Although the registered manager was well regarded and responded positively to inspection feedback, governance systems were not consistently effective in identifying and addressing concerns. As a result, some risks and shortfalls remained unresolved.
People, relatives and professionals were generally positive about the service. Feedback highlighted caring staff, good relationships with the management team, effective partnership working with healthcare professionals and positive support to access community activities, education and employment opportunities. People told us they felt safe and supported.
We found examples of good practice, including medicines management, safeguarding processes, staff training and partnership working. Staff demonstrated kindness, compassion and a good understanding of people's individual needs.
Overall, while people's day-to-day experiences were generally positive, improvements were required to ensure care was consistently safe, person centred and delivered in line with regulatory requirements and the principles of right support, right care, right culture.
People's experience of this service
People and relatives expressed satisfaction with the support provided. However, we found issues relating to privacy, choice, consent and care planning. Some people did not consistently experience the same level of choice and control, particularly regarding accommodation arrangements and access to private space. These concerns were not generally reflected in the feedback received from people and relatives.
People’s experiences of the service were generally positive. People told us they felt safe living at the service and were supported by staff who were kind, approachable and knew them well. People said they felt able to raise concerns and were confident the registered manager would listen and act if needed. They also described having choice and control over aspects of their daily lives, including activities, maintaining relationships and accessing the community.
Relatives who provided feedback were largely complimentary about the care their family members received. They told us staff understood people’s individual needs, communicated well and responded promptly when concerns arose. Relatives and professionals described positive relationships with the management team and said they were kept informed about significant events, healthcare needs and changes in people’s wellbeing.
People were generally supported to access healthcare services and maintain their wellbeing. Relatives gave examples of staff working with healthcare professionals, managing complex health conditions and supporting people to attend appointments. There was also positive feedback regarding community involvement and opportunities for people to pursue hobbies, interests and social activities.
Overall, people spoke positively about the service and described feeling safe, supported and respected. Relatives and professionals were also largely positive about the care provided, although our assessment identified areas where improvements were needed to ensure people’s rights, privacy, choices and preferences were consistently promoted and protected.