Updated 1 July 2025
Date of assessment: 9 July to 21 July 2025. The service is a residential care home, supporting up to 30 older adults. At the time of our assessment, 25 people were living at the home.
This unannounced inspection took place to review the quality of care and compliance with legal regulations. At the last inspection the service was in breach of the legal regulations relating to safe care and treatment, good governance and recruitment. Whilst the provider remains in breach of good governance, they had made enough improvements to safety and recruitment processes and are no longer in breach of these legal regulations.
Quality statements from the safe, effective, caring, responsive and well-led key questions were reviewed at this inspection. For those quality statements not assessed, scores from the last inspection have been used to help generate the key question ratings.
Staff had a good understanding of how to manage incidents and accidents and were trained to ensure they knew how to monitor and respond to concerns of neglect or abuse. Information about behaviour that communicates a need, emotion or distress included detailed strategies to guide staff; to ensure people received person-centred support, whilst reducing risk.
Improvements had been made to the safety of the environment, and the risk of legionella was now mitigated. The provider had implemented more robust recruitment processes, and medication was now being managed safely.
Assessments about people’s histories, needs and preferences were carried out, and included detailed information about people’s communication needs. An electronic care planning system was used to record care interactions.
Staff promoted choice and control, people were supported to make their own decisions and had access to enough meaningful activities. Various reasonable adjustments were made to ensure the service was accessible, and managerial support was available in emergencies.
The registered manager was experienced and demonstrated positive leadership skills. A new system had been introduced to support the availability and confidentiality of information. There was a focus on learning and innovation at the service, with ongoing investment being made to staff development, the environment and other improvements.
However, incidents and accidents were not always shared with the appropriate agencies, and checks to the safety of the environment and equipment needed further improvement. Information about risks to people was not always consistent and several people’s care plans had not been updated to reflect changing needs. Some governance processes needed further review to ensure they were more robust, and fully embedded.
We have asked the provider for an action plan in response to the concerns found at this inspection.