Wisteria Care, located at The Forum, Stourton Way, in Abbey Manor Park, Yeovil, is provided and run by Mr and Mrs S Wortley.
The service seeks to provide support to older people living with dementia, physical disabilities, or sensory impairments, along with people with a learning disability and/or autism.
The new report, published on May 19, said not everyone at the care home received a regulated activity and scored the care home an overall ‘requires improvement.’
It also found breaches of regulations relating to safe care and treatment, the need for consent, and good governance.
The report said that while the provider took some immediate action during the assessment, the governance systems were ‘not robust enough to provide ongoing assurance.’
This followed the service being rated good after the last inspection.
The CQC only inspected the service received by people provided with ‘personal care’, which is help with tasks related to personal hygiene and eating.
At the time of the assessment, there were 89 people using the service, none of whom were autistic or had a learning disability.
The CQC said the assessment was carried out due to concerns they had received about the service.
The CQC assessed the service against ‘Right support, right care, right culture’ guidance.
The report said: “Care plans and risk assessments did not always detail all the required information, and risks had not always been assessed.
“This placed people at risk of harm.
“Medicines were not always managed safely.
“Where people lacked the capacity to make specific decisions, the Mental Capacity Act 2005 was not always followed.”
The report also said there were sufficient staff to meet people’s needs; however, some staff told the CQC they were rushed and travel time was not factored into their runs.
The registered manager was addressing this.
The report also said some staff’s understanding of safeguarding and whistleblowing procedures ‘varied’ but most knew about reporting concerns to external agencies.
The report said the registered manager had taken steps to reinforce safeguarding and whistleblowing information.
The report said: “We received mixed feedback from staff regarding the training, and the registered manager was arranging additional training for staff.
“The governance systems were not fully effective and had not identified the concerns we found during this assessment.
“The registered manager completed checks and audits, but these had not been effective in monitoring quality or driving improvement.
“The registered manager was responsive to our feedback.”
The report said people were treated with kindness and compassion, and staff said they promoted choice and person-centred care – with people and relatives involved in decisions about their care.
The report said staff worked with all agencies involved in people’s care; professionals gave mixed feedback about the service.
It also said most staff felt supported and felt they were treated equally.
The report also said that people and their relatives were largely positive about Wisteria Care.
However, some raised concerns about rushed care, inconsistent timings, and changes in carers.
CQC has asked the provider for an action plan in response to some of the concerns found during the assessment.