During an assessment under our new approach
Date of inspection: 24 September 2025 and 1 October 2025
The service is a residential care home providing support for up to 32 older people some of whom may be living with dementia. This was the first inspection since the service had been registered with the provider.
There was no effective or consistent management at the service resulting in extremely poor oversight of people’s care. There was no manager in post. Managers from the provider’s 2 sister homes were supporting the service remotely but did not visit regularly. The deputy manager did not always have the time needed to carry out necessary managerial tasks such as reviewing care plans.
The provider had not established a good learning culture. Action taken when things went wrong did not mitigate the risk of recurrence. We identified examples of poor care which were repeated despite managers being aware of the shortfalls. Audits were not carried out to monitor the service.
Care plans and risk assessments were missing or had not been regularly reviewed to ensure they remained an accurate reflection of people’s needs.
There were staff vacancies at the service and staff numbers were not always sufficient to meet people’s needs. Staff were not recruited safely, lacked training and were not receiving support through regular supervision.
We identified breaches of regulations in relation to safe care and treatment, consent, dignity and respect, staffing, recruitment and management of the service.
This service has been rated inadequate and 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.
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 have asked the provider for an action plan in response to the concerns found at this assessment.