Our current view of the service
Updated
10 December 2025
Date of assessment: 15 January to 2 February 2026. This assessment included 3 site visits; 3 inspectors, a medicines inspector and a regulatory coordinator were involved in 1 or more of the assessment site visits completed.
This assessment was completed to check the provider had made improvements following enforcement action taken after our last assessment in March 2025, where we found breaches of regulation in relation to person centred care, dignity and respect, need for consent, safe care and treatment, safeguarding, governance, staffing, and recruitment. This resulted in the service being placed into special measures and further enforcement action being taken.
At this inspection the service had failed to make sufficient improvements and continued to be in breach of regulations in relation to, person centred care, need for consent, safe care and treatment, safeguarding, governance, staffing, and recruitment. Additional breaches of regulation were also identified on this assessment in relation to duty of candour and failure to notify. The service had made improvements and was no longer in breach of the regulation relating to dignity and respect.
We continued to find significant shortfalls in the provider’s systems, processes and oversight of service delivery which had not driven improvements in the quality and safety of the service.
In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this on our website after any representations and / or appeals have been concluded.
This service remains 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 user our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.
People's experience of the service
Updated
10 December 2025
During the inspection we spoke with 3 people and 5 relatives.
During our assessment we found significant shortfalls in people’s experience of care, such as neglect of people’s personal care delivery, including nail care and oral health care.
People’s experience of care was not always person centred. Some people’s preferences had not been considered in relation to personal care. For example, a person expressed the assistance of female staff to help meet their personal care needs, however, records demonstrated at times personal care was being completed by male staff.
Where people at the service were living with dementia, we observed the environment did not always reflect best practice to support people with orientation around the home. People were not supported to engage in meaningful activities and appeared to have limited interaction.
Some people living with dementia were not always able to fully discuss their care delivery, we therefore undertook observations in communal areas throughout the day and evening to understand the experience of care for those less able to tell us their experiences.
We observed staff are speaking with kindness and familiarity with people however, some people were spoken with more than others. We observed 3 people sat at dining table that were not getting any interactions with staff. We observed a member of staff spending time to talk to a person. However, they were interrupted by 1 of the management team and diverted away to carry out other tasks.
Feedback we received from people included, “[Staff] are very good here, staff ask how you are all the time but you don't get to have a good conversation", “When you call sometimes you have to wait a bit of a long time” and “Some staff are nice and others are not”. A person told us they wanted to go out but “Wasn't allowed” because "[Their] legs were not very good", they said they would like to "Watch the sky" and “Watch people and the kids go by”. One person was able to tell us about having to wait, and staff not talking to them much. This was supported by our observations. However, relatives spoke warmly about the care staff delivering care, stating they were caring and respectful.