Updated 27 October 2025
Date of Assessment: 10 November to 18 December 2025. The service is a care home with nursing providing support to older people including people living with dementia and physical disabilities.
The provider was previously in breach of the legal regulations in relation to person-centred care, dignity and respect, lawful consent and application of the Mental Capacity Act (MCA), safe care and treatment and governance. We carried out this assessment to check if the necessary improvements had been made.
Improvements were not found and the provider remains in breach of these regulations. We observed unsafe care practices, poor application of the Mental Capacity Act (MCA) 2005, and the statutory requirements for best interests’ decision-making, ineffective risk management, and governance systems that did not reliably identify, mitigate or learn from risk.
The provider was previously in breach of the legal regulation relating to staffing. Some improvements were noted during this assessment; however, further improvements were still required to ensure staffing arrangements were consistently safe and effective.
This provider remains in special measures. The purpose of special measures is to ensure 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.
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.
We found repeated failures in safety systems, leadership, oversight and day-to-day care. There were risks linked to medicines, infection control, the environment, nutrition, skin care, consent and supervision.
People were exposed to avoidable harm because concerns were not consistently acted upon to improve safety. Care plans and records could not be relied on to support safe care. Documentation was often inaccurate, contradictory, overly generic or not practical to use. Risk assessments, care plans and reviews were not aligned, and important events such as falls, and health deterioration were not consistently reviewed to identify where improvements to quality and safety could be made. We were not assured people were consistently receiving safe, effective, dignified and person-centred care.
The provider had experienced ongoing leadership instability. Frequent changes in management affected staff morale, continuity and accountability, alongside long-term improvements to quality and safety. Learning from CQC’s previous assessment had not been properly embedded and safeguarding people, medicines management and learning systems were not consistently effective in practice.
Although many staff showed compassion, skill and commitment, we found gaps in their supervision, slow responses to people in distress, unsafe information sharing between staff, and the use of agency staff without proper induction or oversight
There was improvement in staff conduct and professionalism and staff recruitment processes were safe. Some progress had been made in areas such as activities provision.