During an assessment under our new approach
About the service
This service is a care home. There were 38 people using the service at the time of the inspection in receipt of the regulated activity personal care. The provider is an independent, not-for-profit organisation governed by a board of trustees. The service is located near the town centre and comprises of a residential care home, day centre and independent living accommodation.
Who the service is for
This service supports older people and people living with dementia.
Key findings
We carried out this assessment between the 6 October and 14 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 were treated with kindness, dignity and respect by staff who knew them well. We observed warm and positive interactions, with staff adapting their approach to meet people's individual needs. For example, staff knelt at eye level when administering medicines and used calm, reassuring language when supporting people. Staff understood the importance of promoting people's independence and choice. One staff member told us, “They don’t need our permission. If a resident says, ‘Can I do this?’ the answer is, ‘Of course you can”.
People were supported to take part in activities that reflected their interests and abilities, including access to a neighbouring day centre. We saw people were relaxed and comfortable in the presence of staff and managers.
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. For example, staff were observed knocking on people’s doors to gain consent before entering.
People received safe care from staff who understood their responsibilities and had the skills, knowledge and experience to meet people's needs. The provider had strengthened leadership arrangements through the recruitment of two deputy managers and the introduction of dedicated management oversight across the home. A dedicated staff team was allocated to each floor, supported by deputy managers and senior staff. This improved continuity of care and enabled people to receive more consistent support from staff who knew their needs, preferences, and risks well. Staff spoke positively about these changes, with one commenting, “The new deputy manager roles are absolutely brilliant,” and another stating, “The continuity of care can only improve with the same people being on the same wings all the time.”
The provider effectively assessed and managed risks. Pre-admission assessments were comprehensive, involved people, relatives and relevant professionals, and informed person-centred care planning.
The provider had effective safeguarding arrangements in place. Staff understood how to recognise and report concerns, and records demonstrated the management team responded promptly and worked with partner agencies to help keep people safe. Staff described a positive safeguarding culture. One staff member told us, “Absolutely, I would report concerns. I’d go straight to my shift manager and follow the process.”
People received their medicines safely. The providers governance and audit processes had identified areas for improvement, and the provider took prompt action when issues were identified, including making notifications to relevant authorities and providing additional staff training and competency assessments. Medicines were stored, administered and recorded in line with current guidance.
The provider had made significant investment in the environment and premises. Improvements included upgraded laundry facilities, a dedicated maintenance workshop, secure waste management arrangements and enhanced fire safety systems. Staff had received advanced fire safety training, and systems were in place to monitor environmental risks and support people's safety.
Staff described a positive and supportive culture. One staff member told us, “The managers are very approachable,” while another said, “Even if I don’t know something now, I feel like I can ask and get support.” Feedback from staff consistently reflected confidence in the leadership team and a willingness to raise concerns.
Although we found many areas of good practice, further work was needed to strengthen recording systems on fluid monitoring records. Documentation did not consistently demonstrate the actions staff should take when people failed to meet their prescribed fluid intake targets. Provider oversight was not always evident, as records did not consistently show how management identified, reviewed, and responded to gaps in monitoring.
The provider responded positively to this feedback and demonstrated a strong commitment to continuous improvement. During the inspection, the provider had already begun implementing changes to address these areas and shared a clear action plan outlining the steps being taken to strengthen recording systems and support ongoing compliance.