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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

Responsive – this means we looked for evidence that the provider met people’s needs.

At our last assessment we rated this key question Good. At this assessment the rating has changed to Requires Improvement. This meant people’s needs were not always met.

The service was in breach of legal regulation in relation to person-centred care

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Care plans reviewed lacked meaningful detail and person-centred information. For example, one person’s care plan noted they liked music and birdwatching but contained little further information into their personal history. Other care plans included vague or incomplete information such as for one person recorded as ‘needs to be checked regularly throughout the night’ but gave no detail of how often ‘regularly’ meant.

There were inconsistencies in peoples recorded needs. One person’s dietary care plan stated they should be assisted with meals but not fed; however, staff were seen feeding this person at lunchtime. This meant it was unclear if the care plan was not being followed or if it was out of date.

Some care plans appeared to be duplicated. For instance, 2 people had identical information recorded in their slips, falls, and wheelchair risk assessments. We reviewed the daily records for the month of August for 5 people and found gaps in all of them. Although the registered manager told us some of the issue (at the end of August) was due to transferring daily notes over to an electronic care planning system, this may not have accounted for all of them. Four people had no daily notes between 26th and 30th August and 3 had no notes between the 18th and 22nd August. One person also had no notes written on 5th August and 1 person had identically written daily notes for 9 consecutive days during August, suggesting staff were copying and pasting what they wrote. This meant should care notes need to be reviewed, the service was unable to produce contemporaneous, chronologically arranged notes for everyone.

Conflicting information was also found within people’s care plans. One person was recorded as wearing glasses and using hearing aids, but later it was written they had no sensory impairments. Another person’s nutrition care plan recorded no changes in their weight when the care plan was reviewed, yet the person had been referred to the speech and language therapy team as well as a dietician in July 2025 due to weight loss. This demonstrated poor management oversight and a lack of robust governance arrangements as these shortfalls had not been identified in audits carried out by the service.

Staff told us care plans were reviewed by senior staff and each person had an allocated key worker responsible for updates. However, some staff also admitted they had not read the care plans, with 1 telling us, “I haven’t had time to get them out and read them.”

Despite these shortfalls, we did find more personalised information, such as details on how people preferred to sleep and their bedding preferences. Some care plans also reflected where people were able to undertake tasks independently such as in their personal care.

People said they felt staff knew them well. One person told us, “The staff know me. We have a bit of fun. They got me a lovely birthday present.”

Staff did not always understand the diverse health and care needs of people as we found some shortfalls in care plans as well as daily practice.

One person’s care plan contained limited information on their level of understanding and how the best way to support them. The care plan recorded the person may become verbally aggressive and staff were advised to remain calm if this happened. However, there was no information on potential triggers, de-escalation or communication strategies for staff to help reduce the person’s anxiety. In addition, this person’s care plan noted they had difficulty getting in and out of bed and required staff to support them with this, but it did not specify what type of support was needed such as equipment or 2 staff. This could result in a new or agency staff member not providing appropriate care.

In addition, at lunchtime, we saw all residents were expected to say Grace before eating. This did not appear to take into account people’s individual beliefs or preferences and there was no indication that people had been consulted about this.

However, people fed back they felt the staff attended to their needs with one telling us, “I’ve been comfortable. Food is okay. There is a choice of two things for lunch and dinner.” Other people’s care plans did contain good information however about their daily routines, wishes and preferences. For example, we read 1 person always like to eat their breakfast and supper in their room, but their lunch in the dining room and we saw this happened.

The registered manager provided information in a way that was easy for people to understand. Regular resident’s meetings were held and the registered manager told us the notes of these meetings were printed on yellow paper. This can help make it easier for people to read typewritten information particularly if they have a visual impairment.

There was other information displayed around the service for people to read, such as events taking place, fire information or details about the staff and their roles within the service.

The registered manager made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. A relative told us, “They (staff) were very helpful to us. If there is an issue they will ring or text me.”

Through the resident’s meetings, people had raised ideas on improvements or changes they would like to see in the service, this included making the hydration station more obvious to them as a reminder if was there.

We read the service had received many compliments about the care provided to people’s family members and relatives we spoke with said they had no concerns at raising their feedback.

Staff made sure people could access the care, support and treatment they needed when they needed it.

The registered manager told us, “The hub (local GP practice) telephones on a Tuesday. We always ask people if anyone would like to see the doctor so they can be added to the hub list.”

However, we found some instances where people’s equity in access was not always met. For example, 1 person told us they had never been informed there was an adapted shower in the service and as such they had not had a bath or shower since moving in earlier in the year. We also read in 1 person’s daily care notes, ‘We were unable to take [person] to the dining room as we did not have enough wheelchairs’. This showed a failure to always have equipment available for people resulting in people missing out on accessing communal areas. In addition, wheelchairs being shared suggested that equipment may not have been assessed or tailored to meet each person’s specific needs.

Staff and management were trying to improve opportunities for people to help ensure people had equity in experience in outcomes and a reduced risk of social isolation.

The range and variety of activities appeared limited. This was reflected both in the photographic evidence on display - where many images showed similar group activities - and in feedback from people, some of whom described to us about being bored or wanting more to do. We found little evidence of person-centred or interest-based activities tailored to people’s past hobbies, cultural backgrounds, or life histories. In addition, the activities co-ordinator was only in the service 3 days a week which restricted the time in which people had a dedicated staff member running activities for them. One person told us, “I do like it here, but I get so bored.”

Staff told us that participation in activities was based on people’s choice. Ideas were raised at resident’s meetings and through the activity coordinator speaking on an individual basis to people. In addition, an in-house shop was available giving people the opportunity to purchase small items for themselves.

Group activities took place which included quizzes, bingo, quoits, aromatherapy and singing sessions and some people enjoyed these with one relative telling us, “There are a couple of things going on. He seems happy enough and he talks about what goes on.”

We were also told the activities co-ordinator carried out individual room visits in the morning for people not wishing or not able to come into communal areas.

Staff had previously arranged external outings for people although these had ceased due to accessibility issues. The registered manager explained that as more people now needed to use a wheelchair, they did not have a suitable vehicle to enable them to do this. As a result, the service had raised some funds through an open day event to hire an accessible ambulance for a one-off day trip.

There was no evidence to demonstrate people supported to plan for important life changes including at the end of their life.

We read information had been recorded in relation to people’s resuscitation decisions. For example, some people’s care plans noted if they did not wish to be resuscitated. However, there were no detailed end of life care plans in place recording people’s individual wishes on how they wished to be cared for at this time of their life.