Restgarth Care Home

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

This is the first assessment for this newly registered service. This key question has been rated inadequate. This meant there were widespread and significant shortfalls in people’s care, support and outcomes.

The service was in breach of regulations in relation to safe care and treatment, consent and management of the service.

This service scored 33 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not make sure people’s care and treatment was effective because they did not check and discuss people’s health, care, wellbeing and communication needs with them.

People’s care plans were not all up to date and some had not been reviewed for several months. We identified inaccuracies in some care plans. For example, a relative told us their family member needed support at mealtimes. The person’s care plan stated, ‘[Name] does sometimes need prompting with fluid intake but can drink and eat independently.’ A supporting manager told us they had recently carried out an audit of care plans and were aware they required updating.

When care plans had been reviewed this had not always been done in consultation with people or their relatives.

The provider did not plan and deliver people’s care and treatment with them. They did not follow legislation and current evidence-based good practice and standards.

One person had lived at Restgarth since August 2025. No care plans had been developed detailing their specific needs. There was no guidance for staff to help ensure they had the information they needed to support the person in line with current standards and best practice.

Some people required additional monitoring or support with continence care to protect them from identified risk. This had not been consistently provided. For example, people’s nutrition and hydration needs were monitored and the electronic care system flagged when people had not had sufficient to drink and/or eat. However, this was not being actioned putting people at risk. For example, one person’s recommended fluid intake in a 24-hour period was 1500 ml. Daily records showed they had only consumed 220 ml over the past 24 hours. No action had been taken to address this.

We identified one person who had not been supported with continence care for several hours. However, the care records indicated they had received support. A manager told us this was due to an anomaly in the recording system. Although they were aware of this no action had been taken to address the issue to ensure records accurately detailed the support people had received.

Some people were living with dementia; the design and layout of the premises did not take their needs into account. For example, there was no signage in the building, this can maximise independence and provide clear orientation and personalisation for both residents and staff.

The provider did not always work well across teams and services to support people. They did not always share their assessment of people’s needs when people moved between different services.

We received mixed views from professionals about how the service worked with them. For example, one healthcare professional told us, ‘Management are approachable and receptive to feedback, responding promptly to queries or concerns.’ However, another described the service as ‘absolute chaos.’

Staff attended handovers between shift changes. This did include some key information about people’s needs and any concerns about people’s well-being.

The provider did not support people to manage their health and wellbeing, so people could not maximise their independence, choice and control. Staff did not support people to live healthier lives, or where possible, reduce their future needs for care and support.

People were not supported to take part in meaningful activities which can support their physical and mental health and well-being. Although an activities co-ordinator was employed 3 days a week they were sometimes required to support other areas of the service. Relatives also told us the provision of activities had dropped and a member of staff commented, “There are zero activities except nail care, no stimulation. People don’t go outside because there are not enough staff.” Staffing issues had also restricted people’s opportunities to use the garden during the summer months. A relative commented, “It used to be used a lot. I think I’ve only seen people out there once this year.”

Staff had not always received, or refreshed, training for supporting people with specific needs. For example, only 6 members of staff had up to date training in oral health care, no staff had received training for supporting people with mental health conditions and only 8 members of staff had up to date training for supporting people when they were distressed or anxious. This meant staff might not have the skills and knowledge to support people to manage their health and well-being.

The provider did not routinely monitor people’s care and treatment to continuously improve it. They did not ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

Processes for monitoring people’s health were not consistently followed. For example, there was no evidence of learning following untoward events. Systems for the monitoring of people’s skin integrity and food and fluid intake was not effective.

Where staff had identified concerns in relation to people’s wellbeing no action had been taken to meet their needs. For example, staff had recorded physical observations for one person which identified their temperature was low, blood pressure high and they were hallucinating. No further action was taken in response to these negative indicators to ensure the person’s safety.

The provider did not always tell people about their rights around consent and did not always respect their rights when delivering care and treatment.

The provider was not consistently working within the principles of the Mental Capacity Act 2005 (MCA). Mental capacity assessments had not always been completed appropriately. We identified one person where a decision had been made on their behalf which potentially infringed their human rights. There was no evidence the decision had been taken in the person’s best interest.

However, we heard staff asking for people’s consent before providing care. We heard a member of staff ask one person, “What would you like to happen today.” They went on to ask if they could carry out a personal care task and explained why this was important.