Updated 18 August 2025
Date of Assessment: 04 to 29 September 2025. The service is a care at home service providing support to older and younger people living in their own home living with dementia, mental health conditions, physical disabilities or sensory impairments.
The service had 2 breaches of regulation from the June 2024 assessment in relation to staffing and fit and proper persons employed. The service had 6 breaches of regulation identified at the December 2024 assessment in relation to good governance, receiving and acting on complaints, statement of purpose, fees, display of ratings and notification of other incidents. We issued a warning notice after the December 2024 assessment in relation to good governance. We followed this up in March 2025, the provider had made improvements but continued to be in breach of good governance.
We carried out this assessment to review actions taken by the provider following our last assessment. We assessed 14 quality statements in safe, responsive and well led. At this assessment we found the provider had made improvements and was no longer in breach of regulations relating to staffing, fit and proper persons employed, good governance, receiving and acting on complaints, statement of purpose, fees, display of ratings and notification of other incidents. The overall rating of the service has changed to good.
Improvements had been made to address previous areas of non-compliance. Accidents, incidents and safeguarding concerns were now well managed and actions taken to prevent future occurrence. Key organisational documents such as the statement of purpose and policies and procedures had been updated. People’s care plans were regularly reviewed and people were involved in this process. The provider ensured complaints were managed effectively and were open and transparent when things had gone wrong. Learning was now shared and communication with staff and people was effective. The provider had displayed its Care Quality Commission (CQC) assessment rating at the location.
Governance systems had been revised but further improvement was needed to ensure they were fully robust. We found improvements in recruitment and training had been made but governance systems did not ensure gaps were identified in a timely way or the quality of training always met staff’s needs. The provider did not always evidence areas which required further development to ensure continual improvement. Staff and professionals told us the service had improved. The manager was praised for their engagement with people and ensuring people and staff were listened to.