Updated 20 November 2025
Date of assessment: 26 November to 03 December 2025.
The assessment was carried out to check whether the breaches of regulation issued at our last inspection had been met. The provider was previously in breach of the legal regulation in relation to safe care and treatment, fit and proper person employed and good governance. Improvements were found at this assessment, and the provider was no longer in breach of regulations.
We looked at 9 quality statements in the key questions of safe and well led.
Lessons were now being learned and had been embedded to promote good practice. Incidents forms were now comprehensively filled out and followed up with staff.
The provider now worked with people to understand and manage risks. Staff knew how to manage people’s risks and care plans, and risk assessments now included appropriate detailed information.
Medicines were now managed effectively and fire risks associated with paraffin-based emollient creams were included in risk assessments. Variable dose medicines now contained the required information to support staff in administering PRN “when required” doses safely.
Leaders had attended training to strengthen their knowledge, and there was ongoing training scheduled.
Governance concerns had been addressed, and audits were now effective in identifying where improvement could be made.
The business continuity plan had been updated and contained relevant information for emergency situations.
Daily notes were now being comprehensively completed by staff, with daily oversight to ensure accuracy and consistency.