Temple Ewell Nursing Home

The service was supporting some people living with autism and a learning disability. We assessed the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed autistic people and people with a learning disability respect, equality, dignity, choices, independence and good access to local communities that most people take for granted. The service did not support people in line with this guidance.

The quality of the service had deteriorated since our last inspection. We found significant shortfalls, with 7 breaches of regulation to safe care, governance of the service, staffing, recruitment, consent, safeguarding and person centred care. In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.

The oversight and governance of the service was poor; there was no effective systems in place to monitor the quality of care and outcomes for people. The provider had commissioned a ‘mock inspection’ by an external consultant in March 2026, who had identified shortfalls. However, the action plan development and monitoring had not been overseen by the provider, and the shortfalls continued.

Accidents and incidents had been recorded but had not been investigated and used as learning opportunities. The management team had not recognised potential safeguarding concerns, they had not investigated or reported concerns to the local safeguarding authority. Staff training needs had not always been identified; staff had not always received training to ensure they could meet people’s needs.

Potential risks to people’s health and welfare had not always been assessed, staff did not have detailed guidance to mitigate the risks. Staff had not always used assessment tools and completed documents accurately, to identify risk or deterioration in health.

Staff had not followed the Mental Capacity Act 2005. When people did not have capacity to make decisions about their care, decisions made in their best interests had not been recorded including when restrictions had been put in place.

The provider had not ensured people would be safe in the event of a fire or evacuation such as people’s information not being accurate about how to move them. We told the provider to take immediate action, which they did to keep people safe.

This service is being placed 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.