- Care home
Bulwell
Assessment report published 29 October 2025
Contents
Ratings
Our view of the service
Date of Assessment: 29 July to 1 September 2025. Bulwell is a residential care home service providing support to people with a learning disability and autistic people. During the assessment, the service was providing care and support to 19 people.
The service was previously inspected and rated good overall and requires improvement in the well-led key question, following a comprehensive inspection carried out on 7 and 10 September 2018 (published on 13 December 2018). The report was published following CQC’s old inspection approach using key lines of enquiry (KLOEs), prompts and ratings characteristics. This assessment was initiated due to an assessment having not taken place since 2018.
We assessed the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence, and good access to local communities that most people take for granted.
Throughout our assessment of Bulwell, we identified shortfalls in the way the service was managed. We identified concerns relating to the environment, safe care and treatment, management of medicines, management of risks, safeguarding, and governance.
Multiple fire hazards were identified, including fire blankets in kitchens not being readily accessible, blocked external and internal fire exits, and cluttered areas with combustible materials. Additionally, some personal emergency evacuation plans (PEEP) were incomplete or inaccurate, flammable creams were present without associated risk assessments, a ‘stay put’ protocol in place without clear confirmation that designated areas were fire-safe.
We observed poor hygiene standards across the service. Some furniture and curtains were dirty or damaged, cleaning records were not always accurate, and kitchen practices did not meet safe food hygiene requirements.
The provider was moving from paper documents to an electronic system, but this had not been effectively managed. We saw care plans that were incomplete, inaccurate, and sometimes used language that was not person centred. Key details were missing from care plan documents used by staff to provide a guide on how to best care for people, and internal audits had not identified these issues. During our assessment there was confusion from the management team as to whether documents could be found electronically or on the electronic system and which versions of records were the most up to date versions.
Audits failed to identify significant issues in care quality and safety. Risks were not adequately assessed or mitigated. The provider did not act on known issues, showing a breakdown in the feedback and improvement loop. We saw that the registered manager was making improvements, but many systems were still underdeveloped.
We have identified breaches in regulation in relation to safe care and treatment and good governance.
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.
People's experience of this service
We spoke with people using the service. Some people at Bulwell were not able to give us their view of living at the service. People told us if they were worried, they would talk to staff. People told us staff helped them with their medicines.
We observed people being supported by staff. We saw people were involved in day-to-day decisions about how they spent their time. Some people went out for activities. One person had a packed lunch to go to the park, another went out on a shopping trip with staff and was excited about going shopping and spoke about the places they would be going to with the staff member.
Staff knew everyone by name and could talk to them about their relatives. Staff understood people’s likes and dislikes and the activities which they most enjoyed.
We noted that people’s personal space was personalised and that people had access to a variety of communal lounge areas and a sensory room. However, people’s needs were not effectively considered when allocating them a room to ensure it was the best fit for them. For example, some people liked quieter spaces but were in a noisy environment. This was acknowledged by the management team, and they gave an example of how they temporarily alleviated this by allowing people to access the office. One staff member said, “People just go where there is a vacancy.” This could lead to people being distressed or self-isolating as a result of feeling uncomfortable in their living environment.
We observed many issues with the environment which would affect people’s safety and their experience of living at Bulwell.