During an assessment under our new approach
Date of assessment: 20 to 27 May 2026. Blossom Lodge is a care home, with nursing. People received support across 4 units, 2 providing nursing care and 2 providing residential care. The service supported older people, some of whom were living with dementia and some of whom with a physical disability. We carried out this assessment to provide the service with its first rating. We found breaches of regulation in relation to person centred care, safe care and treatment, premises and equipment, staffing and governance. The service is rated inadequate, and the service has been 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.
People were not consistently protected from harm due to ineffective risk management, unsafe care practices, and poor oversight. People were not always provided with enough staff. Medicines were not always stored and managed safely. Risks posed to people from the environment were not mitigated and the provider failed to implement effective infection, prevention and control measures. However, we found accidents and incidents were recorded and monitored and reported to external agencies where required.
People’s needs were not consistently assessed or clearly documented. Conflicting information within care plans and a lack of evidence-based guidance, meant staff did not always have clear information to deliver safe and appropriate care. Communication systems were not robust; staff were not always provided with effective handovers. Staff did not always follow the principles of the Mental Capacity Act; we found some people lacking appropriate capacity assessments regarding decisions about their care.
People did not always receive individualised or responsive care due to inconsistent care planning, poor communication, and limited staff time. People were not always provided with meaningful activities or stimulation. Whilst there were some systems in place to gather feedback from people about their care and support, improvements were required to ensure care was consistently responsive to people’s preferences and needs.
The service was not consistently well-led. Auditing and governance systems failed to identify and address significant risks we found during our assessment. Leadership oversight was limited, and there was no clear quality improvement plan to drive sustained improvements. Staff feedback about management, culture, and communication was mixed, and not all staff felt supported or able to raise concerns. While the service worked with external professionals, overall leadership, oversight, and organisational culture did not consistently support safe, high-quality care.