- Care home
Breach House
Assessment report published 6 January 2026
Contents
Ratings
Our view of the service
Date of inspection: 21 August 2025 to 05 November 2025. Breach House is a residential care home supporting older people, some of which may be living with dementia. The service is registered to support up to 34 people and at the time of our inspection 18 people were being supported at Breach House. We visited Breach House on 21 and 22 August, 08 October and 27 October 2025 to carry out a comprehensive inspection triggered as a result of the Care Quality Commission (CQC) receiving concerning information from the local authority, alongside an increase in the number of complaints and staff speaking out.
The service lacked a positive safety culture and failed to respond properly to concerns. Safety incidents were not consistently investigated, recorded, or used to improve practice. Risks to people’s health and safety were poorly assessed and not effectively mitigated. Care records were incomplete or out of date, leaving staff without accurate guidance.
There were unlawful restrictions on people’s liberty, including the use of sensor mats and CCTV without proper consent, lack of capacity assessments, and lack of best-interest processes.
Environmental safety was weak. Important checks were not robust, and some hazards, such as windows without appropriate restrictors, had not been addressed despite long-standing guidance. The signage and poor communication created challenges for people living with dementia.
Assessments and care plans were not detailed, person-centred or regularly reviewed, and people were not routinely involved in decisions about their care, including end-of-life planning.
Leadership was ineffective. Managers lacked visibility, oversight and the skills required to ensure safe, person-centred care. Staff morale was mixed, with some reporting that concerns, including alleged medication errors, were ignored or not investigated fully. Supervision, appraisals, and team meetings were infrequent and not meaningful.
Governance systems were weak or absent. Audits failed to identify obvious problems, and there were no effective processes to monitor incidents, analyse risks, or improve the quality of care. Documentation was sometimes altered without explanation, demonstrating a lack of transparency.
Overall, people were put at risk due to poor oversight, governance and leadership. The service breached multiple legal regulations, including those relating to safe care and treatment, environmental safety, incident management, staffing levels, training, supervision, and compliance with the Mental Capacity Act (MCA).
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 time frame within which providers must improve the quality of the care they provide.
People's experience of this service
As part of our inspection, an expert by experience joined our inspection team onsite and helped us gather some of the evidence that we used to make judgements about the quality of care. An expert by experience is a person who has personal experience of using, or caring for someone who uses, this type of care service. People often find it easier to speak to someone who has a similar lived experience to themselves.
People were sometimes unaware of who was managing the service.
People gave mixed feedback about the responsiveness and care, with some reporting difficulty accessing healthcare appointments.
People were exposed to the risk of harm because risks to their health and safety had not been adequately assessed, and not all that was reasonably practicable had been done to mitigate such risks.
People we spoke with told us they felt safe with the staff who provided their care; however, some people told us they didn’t know who the manager was. People were not involved in their care planning.
We received mixed feedback from people and visitors about staffing. People told us they were happy with how their medicines were being managed. People were offered a choice of meals and were mostly positive about the food.
When we spoke to people about whether members of staff were kind and caring, there was a mixed response. People told us complaints in the past had been resolved; however, some people were not always clear on who they would report concerns to or were not asked about their care. People were not able to identify who the manager was.
People were not always supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.