The Coach House SBDP1 Limited

“At the previous inspection, we found the provider was in breach in relation to safety, consent, governance and fit and proper persons. At this inspection, we found while they had met some breaches, they were still in breach of regulations in relation to safety, governance and we found a new breach relating to treating people with dignity and respect.”

“The assessment identified widespread, systemic failings in safety, care quality, governance and person‑centred care. Incident reporting lacked detail and analysis, safeguarding was inconsistently applied, and learning from events was limited. Risk management was not robust, with missing or outdated assessments, a lack of detailed care plans, and inconsistent monitoring of hydration and skin integrity. Environmental and infection‑control issues, including outdated evacuation plans and damaged equipment, increased risks.”

“Medicines management was not always safe, with gaps in documentation, inappropriate covert administration and ineffective audits. Care was not consistently effective, as assessments were incomplete and staff did not always explore health, wellbeing or communication needs. Mental Capacity Act processes were not fully followed.”

“People were not always treated with dignity, and basic hygiene needs were not always met. Activities and independence were limited. Staff morale was mixed, and governance systems remained ineffective.”