Anchor House - Doncaster

We assessed and inspected the service because of concerns we had received about the quality of care and leadership and management at the service. We carried out a comprehensive assessment and inspection of the service covering all 5 key questions and all quality statements.

We found breaches of legal regulations in relation to person centred care, safe care and treatment, infection prevention and control, management of medicines, and governance at the service.

The service was previously rated Requires Improvement at the last inspection (report published 26 September 2025). The service had not sustained or embedded improvements found at the previous inspection and the service is now rated Inadequate.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. The provider shared safeguarding concerns quickly and appropriately. We found the service was working within the principles of the Mental Capacity Act 2005 and if needed, appropriate legal authorisations were in place to deprive people of their liberty. The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs which was safe, supportive and enabled people to do the things which mattered to them. The provider did not always detect and control potential risks in the care environment. They did not make sure equipment, facilities and technology supported the delivery of safe care. The external and internal environments of the care home were not maintained safely. The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care which met people’s individual needs. The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly. Cleaning and disinfection processes were not effective. The provider did not make sure the management of medicines and treatments was safe and met people’s needs, capacities and preferences.

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. 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. The provider did not work well across teams and services to support people. Members of staff did not work together effectively. The provider did not always support people to manage their health and wellbeing, so people could not always maximise their independence, choice and control. The provider did not always routinely monitor people’s care and treatment to continuously improve it. People were not always involved in their care and members of staff carried out care and support as tasks without meaningful engagement.

The provider did not treat people with kindness, empathy and compassion, or respect their privacy and dignity. Members of staff were task focused and did not always interact people in a kind and caring way. The provider did not treat people as individuals or make sure people’s care, support and treatment met people’s needs and preferences. The provider did not promote people’s independence, so people did not know their rights and have choice and control over their own care, treatment and wellbeing. The provider did not listen to or understand people’s needs, views and wishes. Staff did not respond to people’s needs in the moment or act to minimise any discomfort, concern or distress. The provider did not always care about and promote the wellbeing of their staff. They did not always support or enable staff to deliver person-centred care. Members of staff were on ‘zero hours’ contracts which meant there was a risk to the continuity of care and support for people.

The provider did not make sure people were at the centre of their care and treatment choices, and they did not work in partnership with people, to decide how to respond to any relevant changes in people’s needs. There were significant shortfalls in how the provider understood the diverse health and care needs of people and their local communities, so care was not joined-up, flexible or supportive of choice and continuity. The provider did not supply appropriate, accurate and up-to-date information in formats tailored to individual needs. The provider did not always make it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. We did not observe people being engaged in activities by members of staff. People did not have easy access to outside space and there were no links with the local community and community groups. Leaders and members of staff did not listen to information about people who are most likely to experience inequality in experience or outcomes. This meant people’s care was not tailored in response to this. People were not always supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

The provider did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities. The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied an appropriate organisational culture and values. The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them. The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. The provider had limited oversight of quality and improvement throughout the service. The provider did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people.

This service is being placed in special measures. The purpose of special measures is to ensure 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.

In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/or appeals have been concluded.