- Care home
Mr 'C's
Assessment report published 9 October 2026
Contents
Ratings
Our view of the service
Date of assessment: 30 June 2026 to 13 July 2026.
The service is a care home providing accommodation and personal care for up to 40 older people, including people living with dementia. At the time of our assessment, 25 people were using the service. The assessment was undertaken in response to concerns about the quality and safety of care and support being provided.
People were exposed to avoidable risks because governance and oversight systems were not effective. Audits had failed to identify or address many of the concerns found during our assessment, including weaknesses in care records, medicines management, environmental safety, incident monitoring and notification processes. Accident and incident analysis was incomplete, complaints records were not always available, and actions identified through audits had not always been completed. The management team did not have an accurate understanding of the quality of care being provided or the risks people were exposed to.
The evidence gathered during this assessment demonstrated significant shortfalls in the systems used to assess, monitor and manage risk. Risks relating to people's health, safety and wellbeing were not always identified, assessed or mitigated effectively. Care plans and risk assessments often lacked detailed guidance for staff, were not consistently reviewed when people's needs changed and did not always reflect significant incidents or known risks.
We found concerns regarding staffing and workforce oversight. Staff reported there were not always enough staff deployed to meet people's needs in a timely way. This reduced opportunities to spend meaningful time with people and sometimes resulted in delays to care. We identified gaps in training, supervision, appraisal and competency assessment processes, with some staff lacking the knowledge and support required to meet people's needs safely and effectively.
The environment was not always managed safely. We found concerns relating to fire safety arrangements, environmental checks, maintenance records, water safety monitoring and oversight of premises risks.
There were some positive findings. Staff demonstrated knowledge of safeguarding procedures, falls management and emergency processes, and recruitment checks were generally completed. Staff spoke positively about the staff team and knew people well. The registered manager responded promptly to the serious concerns raised and took immediate action to begin addressing some of the issues identified.
We identified 5 breaches of regulation, relating to person-centred care, safe care and treatment, safeguarding, good governance and staffing. At this assessment the overall rating was Inadequate.
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.
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
Feedback from people and their relatives was mixed. Many people told us staff were kind, caring and knew them well. People described positive relationships with staff and said they usually felt listened to, respected and treated with dignity. They told us staff responded when they needed support and helped them to maintain contact with family and friends. Several people spoke positively about the quality of care they received and said they would raise any concerns with managers if needed
People told us they had opportunities to make choices about their day-to-day lives. Some people regularly accessed the local community independently, visited family members and attended appointments. Most people we spoke with were positive about the support they received from care staff and said staff understood their needs and preferences.
However, people’s experiences were not consistent and did not always reflect the quality of care identified during our assessment. While people were generally positive about the staff who supported them day to day, we found concerns relating to care planning, risk management and how people’s changing needs were assessed and responded to. Care records did not evidence people and their relatives were involved in planning or reviewing care, and some records contained incomplete, inaccurate or conflicting information.
A prolonged lift breakdown had a significant impact on some people’s independence, wellbeing and access to the community. One person who used a wheelchair told us they had been unable to leave the building while the lift was out of service and another person said they did not feel safe using the stairs. During our visit, we observed a person with mobility difficulties in distress returning from a healthcare appointment and struggling to access their room upstairs without staff support.
People generally spoke positively about the kindness of staff and inspection observations showed caring interactions between staff and people using the service. Staff demonstrated knowledge of people’s backgrounds, interests and preferred routines. However, some people’s quality of life was affected by environmental issues, access difficulties and a lack of personalised planning to support changing needs.
People gave mixed feedback about food and activities. Some people enjoyed the meals provided and told us there was usually a choice available, while others felt menus could be more varied. People described opportunities to take part in social activities, and a range of activities including bingo, film nights and baking. Although evidence showed limited resources were available to support activities and wellbeing.
Relatives were generally positive about the caring approach of staff and did not raise significant concerns about people’s immediate safety. One relative told us the service had kept them informed during a period when the lift was out of use and said they had no reason to believe their family member was unsafe. However, relatives we spoke to reported communication concerns and told us they had not been involved in discussions about care, risks or medicines.
Overall, people valued the kindness and commitment of staff and many reported positive day-to-day experiences. However, our assessment identified significant concerns about how risks were identified and managed, the accuracy of care records, involvement in care planning, staffing arrangements and oversight of people’s health and wellbeing. As a result, people could not always be assured they would receive safe, person-centred and consistently responsive care.