During an assessment under our new approach
We carried out this assessment on 22 September 2026 until the 2 October 2026. This service was previously rated as good. We carried out this assessment to confirm whether the rating of good remains accurate. This report does not provide detailed information on areas where we found practice continues to meet a good standard. Instead, our findings focus on any areas where the service needs to improve or where we found exceptional practice.
People consistently told us they were happy and felt safe living at the service. A person told us, “I am very happy here.” Another person said, “I like it here very much.” People were safeguarded from the risk of abuse by staff who understood their responsibilities to report concerns. A member of staff told us, “If I had a safeguarding concern, I would follow procedure and raise to the team leader or deputy manager. If it was not being dealt with I could ‘whistle blow’ or I could contact the local authority and CQC.” The registered manager raised safeguarding concerns appropriately and worked with the local authority to investigate these to keep people safe.
Care was person centred and assessments of people’s needs were completed before they started using the service. Care plans we reviewed contained clear descriptions of how people wished to be supported, their preferences, and were individually tailored to meet each person’s needs. Staff assessed and mitigated risks to keep people safe. One staff member told us, “I have looked at the care plans and risk assessments, and we also have a large file that has a short summary of each residents likes, dislikes, risks and a short care plan, which is handy for us.”
People were supported by enough staff with the skills, knowledge, and experience to meet their needs safely. The registered manager regularly reviewed staffing levels to ensure these remained appropriate to people's needs. Staff told us they felt staffing levels were safe, with 1 member of staff commenting, "I do feel we have enough staff." Most people also felt there were enough staff available and told us they felt safe living at the home. The service had systems to monitor staffing levels and respond to changes in dependency and occupancy.
Staff were supported through regular spot checks, management oversight, and an open-door culture. However, staff supervision arrangements had not always been completed consistently. The registered manager had identified this and implemented an action plan to address the shortfall.
Managers had introduced daily walkarounds to provide additional oversight of care delivery, staff practice, and the home environment. Findings were recorded to evidence management oversight and support the timely identification of good practice and areas for improvement.
People received their medicines as prescribed and where needed medicines were regularly reviewed by the GP practice. Staff told us they had their competency checked to support people with medicines safely. The registered manager completed audits of medicines to ensure their systems were working effectively.
The environment was clean and well maintained. The registered manager employed a maintenance person for the day-to-day maintenance at the service. We saw safety certificates were held and up to date, the Avon and Fire Rescue service had visited the home in December 2025 and identified actions for the service to address. These actions had all been completed and addressed. The service was clean and fresh, people told us their rooms were cleaned daily, and they had their personal possessions which made it feel homely.
The registered manager promoted equality in experience and outcome for people. The registered manager had systems in place to measure and monitor outcomes for people, including gaining feedback during resident and relative meetings and surveys. Relatives and people told us communication was good with the service, and they felt confident to raise any concerns. However not all people could recall being asked for feedback.
The registered manager had a positive vision for the home, underpinned by a culture that placed people at the centre of care. Staff spoke proudly about their roles and were positive about the care and support they provided. A staff member told us, “I am proud to work here and enjoy my job. This home is one of the best places to work.” Governance systems were clear, comprehensive, and identified any areas for improvement. Audits were thorough and provided clear oversight of the quality and safety of the home. Where shortfalls were identified, action plans were developed and monitored. The provider maintained an overarching service improvement plan, which included clear objectives, actions, and targets.
People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that staff and management worked within the MCA. DoLS authorisations were appropriately applied for and overseen. People were not subject to unlawful or excessive restrictions they had choice, control, and freedom over their lives.
However, a small number of people commented that staff could appear rushed at times, and 1 person felt additional staffing would be beneficial to meet the needs of people living with dementia.
Staff were completing training; however, records did not always consistently evidence learning undertaken. During the assessment, the provider introduced revised training and learning records to strengthen oversight and recording. These captured both formal and informal learning, including training sessions, discussions, learning conversations, and competency-based support. The system was designed to work alongside the training matrix and other quality assurance processes to demonstrate that staff knowledge and skills were regularly reinforced and reviewed.