During an assessment under our new approach
Date of Inspection 27 July to 27 August 2026. The service is a residential care home providing support to older people living with dementia, mental health conditions, physical disabilities and sensory impairments.
The provider was previously found in breach of the legal requirements relating to Good Governance. During this inspection, we identified further concerns and found the provider remained in breach of Good Governance, as well as additional legal requirements relating to Safe Care and Treatment and Safeguarding Service Users from Abuse and Improper Treatment.
This service 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.
People were not consistently protected from avoidable harm. Risks, safeguarding concerns and changes in people's needs were not always identified, assessed, monitored or responded to effectively. Significant incidents and professional advice were not always communicated appropriately, and systems for learning from concerns and improving practice were ineffective.
There were insufficient numbers of staff to consistently meet people's needs safely and in a timely way. This resulted in delays in support and reduced opportunities for meaningful engagement and person-centred care. Medicines management, risk management and safety monitoring arrangements did not provide assurance that people were receiving safe care and treatment.
People's needs were assessed and people had access to healthcare professionals and support to maintain their physical health. However, care records did not always accurately reflect people's current needs, risks and preferences, and people were not consistently involved in reviewing their care and support. Care was not always delivered in line with people's assessed needs or wishes, and professional advice was not always followed. The provider did not effectively monitor outcomes or respond promptly when people's needs changed. Systems relating to consent and the Mental Capacity Act 2005 were also not always effective.
People and relatives generally spoke positively about staff and staff knew people well and understood their preferences and routines. However, staffing pressures affected people's experiences of care, limiting opportunities for meaningful interaction, personalised support and timely responses to people's needs.
People's individual wishes, preferences and aspirations were not always reflected in the care they received. Opportunities to promote independence, choice, social engagement and wellbeing were inconsistent, and some people experienced limited stimulation and meaningful activity.
Leadership, governance and quality assurance systems were ineffective. Leaders had not embedded a positive learning culture, and concerns identified at previous inspections had not been fully addressed or sustained. People, relatives and staff had limited opportunities to influence the service, and systems failed to identify and respond to many of the issues found during this inspection.
As a result, the provider could not demonstrate effective oversight of risks, quality, performance or outcomes, or provide assurance that people consistently received safe, effective, caring, responsive and well-led care.