During an assessment under our new approach
Date of assessment: 13 May to 1 June 2026. This assessment was prompted due to concerns around the lack of improvements made. Since the last assessment the provider has changed. Since the transfer of ownership, CQC have had numerous engagement meetings with the provider and registered manager.
The provider was in breach of 11 legal regulations related to person-centred care, dignity and respect, consent to care and treatment, safe care and treatment, safeguarding, nutrition and hydration, premises and equipment, good governance, safe and effective staffing, fit and proper persons employed and failure to notify.
We found significant concerns and were not assured that people always received safe, effective, good quality care. The provider failed to protect people from abuse and did not always share safeguarding information as required. Risks to people and health and safety were not always assessed or safely managed. Medicines were not always managed safely.
We were not assured staff always had the skills, knowledge and training to meet people’s needs. There were significant shortfalls in the providers recruitment practices, and they could not demonstrate they met their legal requirements.
People’s care plans lacked guidance in relation to the potential risks associated with their diagnosed medical conditions. Risk management plans were not always in place, robust or reviewed to reflect the care people required. Where people lacked mental capacity to consent to their care and treatment, mental capacity assessments and best interest decisions had not been completed in accordance with the Mental Capacity Act 2005.
The care being provided to people was not person-centred and records failed to demonstrate care provided to people considered their needs and preferences. We were not assured that baths, showers and oral hygiene were regularly offered or provided to people to maintain their basic hygiene needs and ensure they were supported in a dignified way. People were not always treated with dignity by staff. People did not consistently receive person-centred and appropriate care that was responsive to their needs.
The provider failed to operate effective checks of care quality and safety. The provider’s governance processes did not identify the issues we found during this assessment. Quality assurance systems and processes were not effectively implemented to ensure safety and drive improvement. The provider failed to notify the commission of safety events where they were required to do so.
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.
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.