Updated 20 April 2026
Date of assessment: 27 May to 15 June 2026.
This comprehensive inspection was prompted in part by notification of an incident and our ongoing monitoring. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of the incident.
The service is a care home with nursing which supports up to 55 older and younger people who may be living with dementia.
Since the last inspection, the registered manager, provider and staff team have made a number of improvements to practice, processes, and the environment. However, further improvements were required, particularly in relation to governance, consent, and staffing. Systems were not sufficiently robust to ensure all relevant information was consistently reviewed, which prevented a full understanding of the potential risks and factors affecting people’s safety and experience. Staff did not demonstrate consistent knowledge, or application of the Mental Capacity Act (MCA) 2005, which negatively impacted people’s rights. The registered manager was unable to evidence people had consented to their care plan. There were not always enough staff deployed and available throughout the day to meet people’s needs in a timely way. This was most evident at lunchtime, when many people required support.
People’s daily records did not evidence their incontinence products were changed as frequently as required within their care plan. Whilst the registered manager told us people had received this care, there was a lack of written evidence to confirm this.
The service was in breach of 3 regulations relating to consent, staffing, and good governance.
We also identified further areas for improvement were required within the key question of safe; including in relation to: safeguarding, risk management, safe environments, infection prevention and control, and medicines management.
The provider’s care planning process did not consistently capture sufficient written detail about people’s individual routines and preferences to guide and inform staff. For people living with dementia, their care plan did not clearly describe how their dementia impacted them unless they required a behavioural support plan. People’s religious beliefs were only noted within their end-of-life care plan, rather than also within their general care plan.
Although the overall rating for the key question of caring has improved to good, some aspects still required improvement.
The provider had a clear vision for the service centred on the provision of person-centred care and upholding people’s rights; however, further work was needed to fully achieve this. Whilst the registered manager was experienced, they were not fully aware of all CQC notification requirements.
However, there was a proactive and positive safety culture. Staff reported incidents appropriately, which were investigated and necessary actions taken. The registered manager analysed incidents for any trends that required action. Pre-admission assessments were thorough, and information was shared effectively.
Staff worked collaboratively with external agencies and healthcare professionals, who provided positive feedback. Staff used a range of clinical tools to assess and monitor people’s needs and risks, and people were supported to access healthcare services.
Staff surveys showed some staff felt they had to work very fast which meant they lacked the time to provide person centred care. Staff also felt valued and well supported within their role. They felt they had the training and supervision required to do their job.
The provider had made a range of improvements to the home and gardens which had improved both people’s comfort and experience. There was air conditioning which kept people cool in hot weather. People had a choice of spaces to sit both inside and outside.People’s birthdays were celebrated and seasonal events and celebrations at Christmas.