Archived: Purbeck House Care Home

Updated 17 June 2025

This assessment was in response to concerns raised with the Care Quality Commission (CQC). Purbeck House Care Home is a care home that can accommodate up to 15 people. At the time of our assessment there were 12 people living at the service some of whom were living with dementia.

At this assessment we identified 9 breaches of the legal regulations in relation to safe care and treatment, staffing, safeguarding people, person centred care, dignity and respect, fit and proper persons employed, consent, good governance and failure to notify.

The management team and staff consistently lacked knowledge and understanding of people’s past and current medical needs. Without this information they could not be aware of what and how to monitor people’s needs and health conditions to help ensure effective, person centred care and treatment. This meant people would not always be protected from the risk of harm and ill health. We identified a lack of effective monitoring and mitigation in relation to risks including, dehydration, constipation, falls, skin breakdown and choking.

People were at risk of or were experiencing harm and or abuse. We found significant shortfalls in the provider’s safeguarding processes and ineffective systems to manage incidents, accidents, near misses and potential safeguarding concerns. Accident and incident records lacked details about each event and there was no evidence to show events had been analysed to identify any themes, trends or ways to mitigate the risk of further occurrences.

People did not always receive their medicines safely and medicines were not always stored safely and securely. The provider and management team were not clear of their responsibilities in relation to compliance with health and safety requirements. The provider failed to ensure staff had relevant and up to date training or that there were safe recruitment systems to ensure people were receiving care from suitable staff. Systems and processes in place to gain people’s consent and make decisions were ineffective and did not demonstrate care was always provided in line with the law.

People, relatives and staff were not always given the opportunity to provide feedback and make suggestions about the care they received and we were not assured people were treated with dignity and respect.

Governance and oversight was ineffective. The management team failed to complete effective audits and quality assurance processes to ensure care provided was safe, effective and responsive to people’s needs. Where audits were completed, we identified significant shortfalls in the quality of these audits and they failed to identify the widespread and serious concerns we found. In addition, the provider had not consistently notified the commission of all notifiable events as required by our regulations.

Although we found the provider and nominated individual demonstrated they were caring, and it was clear they wanted to provide people with safe, effective and person-centred care, they and the additional management support in place demonstrated that they lacked the skills, knowledge and experience to achieve this.

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 that 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.

Updated 17 June 2025

During the inspection we spoke with 7 people and 2 relatives, this included conversations with relatives both on and off site.

People and relatives spoke warmly about the staff including the provider and nominated individual, describing them as kind and caring. However, during our assessment we found significant shortfalls in people’s experience of care. People’s care records lacked information about people’s likes, dislikes, interests, abilities and wishes and did not contain detailed information of how they liked to receive care and support. This meant staff were not provided with detailed guidance on how people could be supported in a person-centred way.

There was a lack of meaningful activities provided to people to engage them. People, particularly those with a cognitive impairment, were observed sitting in silence for extended periods with little interaction or stimulation.

Where people at the service were living with dementia, we observed the environment did not always reflect best practice to support people with orientation around the home.

The dining experience was rushed, impersonal, and staff did not engage with people in a meaningful way. People were not supported or encouraged to eat healthy balanced diets which met their specific needs. On review of the menus we noted meals often lacked variety and there was limited choice.