Mr 'C's

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question Good. At this assessment the rating has changed to Inadequate. This meant there were widespread and significant shortfalls in people’s care, support and outcomes.

The service was in breach of legal regulation in relation to people’s safe care and treatment, person-centred care, safeguarding, good governance and staffing.

This service scored 29 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not make sure people’s care and treatment was effective because they did not check and discuss people’s health, care, wellbeing and communication needs with them.

People were at risk of receiving ineffective care because their needs were not consistently assessed, reviewed or reflected in care plans and risk assessments. Pre-admission assessments did not always lead to the development of detailed care plans and risk management strategies, meaning staff did not have sufficient guidance to support people safely. In one example, a person with complex health needs was admitted to the service without adequate care planning or risk assessments to manage their identified risks, placing them at significant risk of harm.

Care plans, risk assessments and associated records did not consistently reflect people's current health conditions, identified risks or changing needs. Significant gaps were identified in the assessment and management of conditions and risks including diabetes, catheter care, behaviours of concern, falls, pressure care and bowel management. Reviews were not routinely completed following incidents or changes in need, and risks identified through daily records and incidents were not consistently incorporated into care planning.

Records were incomplete and, in some cases, missing key information, including mental capacity assessments, best-interest decisions, behaviour monitoring records and body maps. Although managers described processes for involving people and their relatives in assessment and care planning, inspection findings did not demonstrate this was consistently taking place in practice.

These failings meant the provider could not be assured people's needs were fully understood, regularly reviewed or appropriately responded to, increasing the risk of inconsistent and unsafe care.

The provider did not plan and deliver people’s care and treatment with them. They did not follow legislation and current evidence-based good practice and standards.

People were at risk of avoidable harm because care and treatment were not always planned or delivered in line with current legislation, evidence-based guidance and recognised good practice. Staff did not consistently have the training, support or guidance required to meet people's needs safely, and risk assessments often lacked clear instructions for managing identified risks.

Care records did not always provide staff with sufficient guidance on the management of complex health needs, including diabetes, blood glucose monitoring and responding to medical emergencies. In one case, senior staff failed to respond appropriately to concerns regarding a person at risk of hypoglycaemia, which resulted in significant harm and an emergency hospital admission.

Training records demonstrated significant gaps in mandatory and role-specific training, including safeguarding, mental capacity, dementia care, diabetes management, nutrition and person-centred care. Staff supporting people with alcohol dependency and alcohol-related brain damage had not received specialist training to equip them to meet these needs safely.

Although leaders had identified these gaps and had begun arranging additional training in areas such as alcohol dependency and diabetes care, these improvements had not yet been implemented sufficiently to improve practice. As a result, the provider could not demonstrate care and treatment were consistently delivered in accordance with current evidence-based standards or staff possessed the knowledge and skills required to support people safely.

The provider did not work well across teams and services to support people. They did not share their assessment of people’s needs when moving between different services.

The provider could not demonstrate staff, teams and partner agencies worked together effectively to deliver coordinated care. While leaders described regular handovers, multidisciplinary meetings and joint working with health and social care professionals, inspection findings showed important information was not consistently shared, recorded or acted upon. External agencies reported the service as being difficult to engage with on occasion.

Staff reported weaknesses in communication within the service. Although some staff described effective relationships with external professionals supporting people with complex health and substance misuse needs, others told us communication between the management team and staff was poor. Comments included, “The care plans and risk assessments are so-so – they are ok, I don’t think there is much communication with staff. They are updated but we don’t have the time to sit and read them. The handovers are ok, but I think some pieces of information do not get handed over to the staff,” and “I have not had any supervision since I have been here or been part of any staff meetings. The communication in general between staff and management is poor.”

These concerns demonstrated systems for communication, information sharing and collaborative working were not sufficiently effective to ensure people's care was consistently coordinated, reviewed and delivered in response to their changing needs.

The provider did not always support people to manage their health and wellbeing, so people could not always maximise their independence, choice and control. Staff did not always support people to live healthier lives, or where possible, reduce their future needs for care and support.

Care planning, monitoring and risk management arrangements did not always provide assurance people's health needs were being effectively assessed, monitored and responded to. Concerns were identified in relation to diabetes management, constipation monitoring, pressure care, falls prevention and catheter care. Care records were not consistently updated when people's needs changed, and identified risks were not always appropriately mitigated.

Some people spoke positively about the care they received and felt staff understood their needs, commenting, “They have a good understanding of my needs” and “If my [health condition] flares up, they will take a picture and send to the GP. Then the doctor will come.” However, others and their relatives raised concerns about the management of health conditions. For example, one relative told us they had never been involved in developing or reviewing their family members care plan and expressed doubts about whether their health condition was being managed effectively saying. “[Family member] has always had a dodgy tummy. Are they giving them food they shouldn’t eat? Are they still on omeprazole twice daily?”.

Staff also reported staffing pressures affected their ability to provide meaningful engagement and wellbeing support, increasing the risk people would not receive person-centred care or appropriate support to maintain their health and independence. Overall, the provider could not demonstrate people were consistently supported to achieve and maintain good health outcomes.

The provider did not routinely monitor people’s care and treatment to continuously improve it. They did not ensure outcomes were positive and consistent, or they met both clinical expectations and the expectations of people themselves.

The provider could not demonstrate people received regular and effective reviews of their care and support needs. Opportunities to identify deterioration, evaluate the effectiveness of care, and make changes to improve outcomes were frequently missed. This meant people could not always be assured that their care reflected their current needs or that risks to their health, safety and wellbeing were being appropriately monitored and responded to.

Following the breakdown of the services only lift on 16 June 2026, the provider did not complete individual assessments or put appropriate measures in place to manage the impact on people living in the service. As a result, some people experienced difficulties accessing facilities, attending appointments and maintaining their usual routines, and risks associated with mobility, independence and evacuation were not effectively mitigated.

Care plans and risk assessments were not routinely reviewed following incidents, changes in need or emerging risks. Information recorded in daily notes and incident records was not consistently translated into updated care plans or risk reduction measures, meaning staff did not always have clear and current guidance to support people safely. For example, staff had documented several incidents where one person had displayed behaviour that posed a sexual risk to care staff. Despite these incidents being recorded, there was no corresponding risk assessment, behavioural support plan or guidance within the person's care records to help staff understand, manage or reduce the identified risks. This left staff without the information they needed to respond consistently and safely and increased the risk of harm to both the person and others.

The provider did not tell people about their rights around consent and did not respect their rights when delivering care and treatment.

The provider did not always ensure people's rights in relation to consent, mental capacity and decision-making were protected. Although we observed, and people told us, staff sought their consent before providing care, records showed mental capacity assessments and best-interest decision-making processes were not completed consistently or in accordance with legislation.

Inspection findings identified gaps in mental capacity and best-interest documentation, including blank assessment records and incomplete decision-making records within care files. In some cases, there was no evidence capacity had been assessed before decisions were made on behalf of people. For example, one person living with dementia was prescribed diazepam on an "as required" basis for agitation, however records showed the medicine was being administered routinely each morning. There was no mental capacity assessment or best-interest decision recorded to support this practice.

The provider also failed to ensure appropriate assessments were completed where people were involved in managing their own medicines. In one case, a person with a known history of being unable to manage medicines safely, where there were concerns about their capacity, was provided with medicines to self-administer without evidence of a mental capacity assessment, best-interest decision or risk assessment.

Staff knowledge and understanding of the Mental Capacity Act was limited. Training records showed significant gaps in MCA training, and staff told inspectors they had not received formal training in this area. They told us, “I've never had any mental capacity training. I think I've self-learned over time about when somebody with alcohol dependency might lack capacity because of drinking too much alcohol.”

As a result, the provider could not be assured staff had the knowledge and skills required to support people to make decisions, assess capacity appropriately or act in accordance with legal requirements when people lacked capacity.

These failings increased the risk that decisions about people's care and treatment were not always made lawfully or in their best interests.