Our current view of the service
Updated
16 January 2026
This assessment commenced on 29 January 2026, when inspectors visited the care home. We
continued to review information and communicate with the provider after this and finished the
assessment on 12 March 2026.
The reason for this assessment was to follow up on the 3 breaches of 3 legal regulations which
were found in our previous assessment, in March 2025. Those breaches were in relation to safe
storage and management of medications, managing risks, restrictive practices and oversight of
the service.
We found during this assessment, that the concerns relating to safe storage of medication had
been addressed and resolved. We found improvement in relation to managing risks and
restrictive practices; however, we were not assured that the concerns relating to management of
medications and oversight of the service had been addressed. In addition, we found concerns in
relation to infection prevention and control.
The provider did not always have systems to effectively manage medications, and where these
were in place, they were not embedded effectively. There continued to be poor practice around
medication management.
The provider did not always have effective systems in place to ensure robust oversight of the
service, including infection prevention and control, and where systems where in place, they were
not completed effectively.
We have asked the provider for an action plan in response to the concerns found at this assessment.
People's experience of the service
Updated
16 January 2026
This was a targeted assessment, looking at governance and processes of the provider,
therefore we did not get feedback from people or relatives as part of this process. The below is
the people’s experience summary from our assessment completed in March and April 2025.
Feedback from people using the service was mixed. Overall, people told us they were happy
with communication and the provider had been open and honest when mistakes were made,
including when accidents had happened, such as falls. One person said, “They (the provider)
are quick to let us know anything”. People felt that staff were polite and respectful, but there was
not enough of them.
People said they were not involved in the planning of care and would have liked to have been,
although they acknowledge that they are involved in reviewing their care and support needs at
least twice a year.
People felt that when they raised concerns, they were either not listened to, or things improved
for a period before reverting to how it used to be. One relative said, “Whenever I raise an issue,
an explanation is provided and it improves for a while, then goes back”. People felt that the
laundry process was ineffective and despite raising concerns, nothing had been done.
People raised concerns with the cleanliness and the support they received with personal
hygiene. One person told us that they deep clean their relative’s room every fortnight as it gets
so dirty. People reported finding their relatives in undignified and unhygienic situations. One
relative had been told to expect to find their relative like this as it was the nature of their
condition, by a member of staff.
People raised concerns with the environment. One person described it as “tired and worn”,
others felt the décor was outdated and the place was generally rundown.
Some people could not directly tell us about their experience. We used observations to assess whether they received good care. This showed mostly positive interactions between people and staff.