- Care home
Archived: 23 Perryn Road
Assessment report published 17 March 2026
Contents
Ratings
Our view of the service
The assessment took place on 12 January to 23 January 2026. The last rating of the service was good (on 4 December 2019). This assessment of the service was undertaken due to the several safeguarding concerns.
23 Perryn Road is a 'care home'. The service is registered to provide personal care to younger adults and people with a learning disabilities or autistic people.People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. At the time of the assessment, 6 people were using the service, and 1 person was in hospital but was still receiving care and support by care staff.
At our last assessment we rated this service good. At this assessment the rating has changed to requires improvement.
We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it. We found that the provider did not always meet the principles of ‘Right support, right care, right culture.’
The service was not always operating safely or consistently. There were repeated failures in incident reporting, safeguarding escalation, risk assessment, and environmental safety. Staffing levels, fire precautions, medicines management, and infection control were also inconsistent, exposing people to avoidable harm.
Care was similarly inconsistent. People had fewer meaningful activities, limited engagement, and variable continuity of support. Relatives reported declining communication and said people were not always treated with dignity, compassion, or as individuals. Although some caring practice was observed, it was not consistently embedded across the workforce.
The quality and safety of care requires improvement. Safeguarding and incident reporting were unreliable, risk assessments were incomplete or out of date, and concerns were not always escalated appropriately. Care planning and monitoring were inconsistent, with gaps in health assessments, nutritional oversight, and involvement of families, meaning people’s needs were not always effectively understood or met.
Leadership and governance were not consistently effective. Frequent management changes, no registered manager in post and repeated issues identified in audits and staff meetings showed a lack of sustained oversight. The local authority had already begun supporting the service prior to inspection due to these and other concerns. The provider has since notified CQC of its intention to close the service.
We found 10 breaches in relation to person-centred care, dignity and respect, need for consent, safe care and treatment, safeguarding service users from abuse and improper treatment, premises and equipment, good governance, staffing, duty of candour and notifications. Most of these breaches were already identified by the provider at the time of our assessment.
We have asked the provider for an action plan in response to the concerns found at this assessment.
People's experience of this service
People’s experiences of the service were inconsistent. While some staff demonstrated caring interactions and supported people to make simple, everyday choices, this was not consistently embedded. Relatives described a decline in communication and involvement, saying they were no longer routinely invited to reviews or informed about incidents or injuries, and some felt discouraged from raising concerns.
Relatives told us activities had reduced significantly, with people often spending long periods unengaged, and previous community opportunities had stopped. Families also reported frequent loss of clothing and bedding, affecting dignity and personal identity.
Relatives told us they were not always included in planning for changes in health or wellbeing, and there was no evidence of discussions about future wishes such as end‑of‑life preferences.