Anchor House - Doncaster

The following is CQC's published account of its assessment, published 26 September 2025. References to “we” mean CQC. It describes findings at that time.

Date of assessment: 19 August to 5 September 2025. We visited the service on 19 August 2025 and spent time observing people’s care and reviewing records and information. Anchor House – Doncaster is a 'care home.' People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Anchor House – Doncaster is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Anchor House – Doncaster can provide personal care for up to 23 people. At the time of our inspection there were 20 people using the service, some of whom were living with dementia. We carried out this assessment under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. The provider was previously in breach of legal regulations in relation to person centred care, safe care and treatment, safeguarding and good governance. Improvements were found at this assessment and the provider was no longer in breach of these regulations. The improvements evidenced at this assessment needed to be sustained and embedded into practice so the provider and the service can continue their journey of improvement.

There was a learning culture in the organisation. Accidents and incidents were logged, reviewed and analysed on a monthly basis to identify learning and improvement. The provider needed to improve how it shared information between services. We discussed this with the management team and immediate changes were made but needed to be embedded into practice. The provider shared concerns quickly and appropriately and they knew how to refer any concerns about safety or suspected abuse to the local safeguarding adults team. The provider did not always detect and control potential risks in the care environment. They did, however, make sure equipment, facilities and technology supported the delivery of safe care. The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide care which met people’s individual needs. Improvements had been made to the cleanliness of the care environment following the previous inspection. The clinical infection prevention and control team had identified the need for attention to detail to cleaning practices specifically around fixtures and fittings. There had been improvements to the management of medications following the last inspection of the service. We identified some areas for improvement around how rotations of people’s pain patches were documented and recorded and how protocols for ‘as and when’ (PRN) medication explained how people would indicate they were in pain or needed their PRN medication. We raised these issues with the management team and they took immediate action and made the changes which mitigated the risk.

People and their families were involved in discussions to ensure care plans reflected people’s personal preferences and care needs. The quality of care plans had improved since last inspection and a new system of care plan reviews had been put into place. The new quality assurance processes to monitor and review the quality of care plans and to ensure care was delivered in line with people’s care needs needed to be embedded and sustained. The manager was new into post and was going through the CQC registration process to become the registered manager. The management team had developed new systems and processes and needed to ensure they were embedded into standard practice. The provider supported people to manage their health and wellbeing to maximise their independence, choice and control. People were asked about their consent to care and support and their decisions recorded. People’s capacity to make decisions was reviewed under the Mental Capacity Act 2005 (MCA).

The provider always treated people with kindness, empathy and compassion and respected their privacy and dignity. Members of staff were kind and caring in their interactions with people and we saw people responded positively to these interactions. The provider treated people as individuals and made sure people’s care, support and treatment met people’s needs and preferences. They took account of people’s strengths, abilities, aspirations, culture and unique backgrounds and protected characteristics. The provider promoted people’s independence, so people knew their rights and had choice and control over their own care, treatment and wellbeing. The provider had improved how the service listened to and understood people’s needs, views and wishes. The changes needed to be embedded and sustained.

The provider made sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs. The provider made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. Staff involved people in decisions about their care and told them what had changed as a result. Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

The provider did have a newly created shared vision, strategy and culture. The provider and the management team needed to ensure the new vision and values were fully understood and embedded with the new care support team. The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. The provider had clear responsibilities and systems of accountability. New governance and quality monitoring systems had been introduced and were in the process of being embedded into standard practice. The new systems needed to be carefully monitored and reviewed to ensure they continued to identify areas for improvement. There was evidence of learning and improvement following the previous inspection and there was focussed approach to person-centred care and support. Improvements and changes needed to be sustained and embedded along with a consistent review of systems and processes to support a culture of continuous improvement.

This service has been in Special Measures since 14 May 2025. The provider demonstrated improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions, therefore, this service is no longer in Special Measures.