Updated 15 July 2025
Date of assessment: 20 August to 1 September 2025
We found 2 breaches of the legal regulations in relation to safe care and treatment, and governance.
Staff had not consistently protected people from risks to their health and safety. Managers had not always followed the provider’s policies and procedures when safeguarding incidents occurred. Improvements were needed to the safety of the premises. Staff had not had the training they needed to meet the care needs of all the people using the services. Medicines storage and management were not always safe. Lessons were not always learnt when things went wrong.
Governance systems and audits were not always effective in identifying or addressing areas for improvement. Audits were not completed consistently and some contained inaccurate information. When shortfalls were identified, audits did not always state the action needed to address them. Staff supervisions and appraisals has not taken place in line with the provider’s policies and procedures.
Staff needed training to support people living with certain health conditions. Most people’s healthcare needs were documented in their care plans and staff referred them to GPs and other healthcare professionals when necessary.
People had detailed care plans setting out their physical, mental, emotional, and social needs. However, people were not always receiving the level of personalised care and support their care plans promised.
Information provided to people at the service was not always accessible to them and did not meet their communication needs. Reasonable adjustments had not always been made for people who needed them.
Most staff were caring and kind and treated people with respect. They responded quickly if people needed assistance. There was a lack of activities at the service and most people had nothing to do but watch television.
Staff had limited opportunities to provide feedback, raise concerns, or suggest ways to improve the service.
People's nutritional needs were mostly met. Staff sat with people at mealtimes and ensured they had the support they needed to enjoy their meals. People had mental capacity assessments to determine if they were able to consent to care.
At the time of our inspection there was no registered manager in post. Following our inspection the provider appointed a new manager to oversee the service.
The provider was open and honest about the challenges the service faced. They had listened to people and relatives and in response upgraded the environment and created a secure garden space. They were committed to working with CQC and the local authority to ensure the service improved.
We have asked the provider for an action plan in response to the concerns found at this assessment.