- Care home
Tapton Grove
Assessment report published 15 September 2025
Contents
Ratings
Our view of the service
Dates of assessment: 21 July 2025 to 4 August 2025
This service is a residential care home providing personal and nursing care for up to 61 people, including individuals living with dementia and those requiring mental health support. At the time we started our assessment, 36 people were living at the service. We completed this assessment in response to concerns about the service we received from partner agencies and the public. We looked at all the quality statements in the key questions of safe, effective, caring, responsive and well-led.We found 3 breaches of the legal regulations in relation to safe care and treatment, need for consent, and governance.Whilst some safe practices were in place, people were at risk of harm and some regulations were not met due to the provider’s failure to consistently identify and mitigate risk. Where actions were taken, they were often unclear, uncoordinated, and lacked effective oversight. Environmental risks were not properly assessed or managed. Additionally, infection prevention and control measures required significant improvement to ensure people's safety. Medicines were not always managed safely. There were widespread shortfalls in the care and support provided. Care did not consistently reflect current evidence-based guidance, best practice, or recognised standards. The service did not ensure that people’s mental capacity was assessed when necessary, nor were consent to care and best interest decisions obtained in line with legal requirements, including the Mental Capacity Act and Deprivation of Liberty Safeguards.The service was not consistently caring. People’s privacy and dignity were not always maintained, and they were not always informed about which staff would be providing their care. There were concerns about people’s dignity and confidentiality. The service did not always meet people’s needs. Governance systems were ineffective and had failed to identify or address the significant concerns found during the assessment. The culture within the service was poor, characterised by low staff morale. Staff reported feeling burnt out, and not always heard by the management team due to limited action taken in response to their feedback.As a result, the service is being placed into special measures. The purpose of special measures is to ensure that services rated as inadequate make significant improvements. This framework allows CQC to use enforcement powers where necessary and sets a clear time frame for the provider to improve the quality of care delivered.
People's experience of this service
Whilst some people we spoke with expressed they were happy with their care, our assessment found elements of the care did not meet the expected standards. We received mixed feedback from people using the service.This reflected our concerns relating to people’s care. We also carried out observations when people could not tell us about their experience.Feedback from people highlighted several consistent themes. A key concern was the lack of stable staffing, which affected their ability to build trusting relationships and receive consistent support. Many said they felt unsettled by frequent staff changes, were unsure who their key workers were, and often did not have structured time with them. This inconsistency sometimes made people reluctant to raise concerns or ask for help.The environment was described by some as isolating, with many people spending most of their time in their bedroom. Opportunities for meaningful activities were limited, with some activities not reflecting people’s interests and others delayed or cancelled due to staff shortages. Staff were often perceived as overworked and fatigued, which further impacted the level of engagement and support available.Although the provider evidenced through residents’ meeting minutes that meal choices were discussed, people told us that the overall quality of meals was poor, with some describing them as poorly cooked.Experiences with staff varied. Some people spoke positively about individual staff members, describing them as caring and supportive. However, others felt that respect and attentiveness were inconsistent. Some people reported they could choose when to have a bath or shower; however, this level of choice was not always accommodated in practice, with some individuals telling us their preferred times were not consistently respected or facilitated.Communication and involvement in care planning were inconsistent. Some people had contributed to their care plans, but most reported no input with any updates. People were aware of the nurse call system but reported varying response times. People described the management as approachable when present but not consistently visible, leading some to feel the service was not well managed.Some people reported weakened links with community services, particularly those placed out of area. One individual told us they had not seen their community worker for over two years. While this falls under the remit of external professionals, there was no evidence that the service raised concerns and advocated on behalf of individuals where ongoing professional input appears to have lapsed.