During an assessment under our new approach
We carried out this assessment on 6 July 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 received care from staff who were kind, caring and knew them well. During our inspection, we observed positive and respectful interactions between staff and people. People were listened to, involved in daily decisions and supported in a way that promoted their independence and wellbeing. Staff responded promptly when people needed support and created a relaxed and friendly atmosphere, with laughter and meaningful engagement evident throughout the day.
Staff demonstrated a good understanding of person-centred care and spoke passionately about supporting people as individuals. One staff member told us they always tried to build a relationship with people by finding out what they liked and disliked and understanding "Who they are." Staff described how they tailored support around people's preferences and choices, including supporting people to enjoy activities and routines that were important to them. Another staff member explained person-centred care meant “Ensuring people remained at the centre of all decisions and that their individual preferences were respected.” Staff also recognised the importance of promoting independence and encouraging people to remain as active and engaged as possible. For example, staff explained how they encouraged people to walk short distances where appropriate, while ensuring additional support was available if needed. This helped people maintain their mobility, independence and overall wellbeing.
Staff demonstrated a compassionate understanding of how to support people living with dementia. They described using reassurance, distraction and personalised approaches to reduce distress and support people's wellbeing. People's needs were assessed before they moved into the service and staff told us effective handovers took place throughout the day to ensure changes in people's needs were shared and responded to appropriately.
Staff understood their safeguarding responsibilities and were able to clearly describe how they would recognise, report and escalate concerns, including concerns involving colleagues or managers. Staff also completed fire safety training and drills and were confident in the procedures to follow in the event of an emergency.
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.
Feedback from professionals was positive. One professional told us they would have "No hesitation" in a family member receiving care at the service and said staff "Went above and beyond" for people.
There was a positive and caring culture within the service; however, some improvements were needed to ensure systems and processes consistently supported safe and effective care. Staff had access to a range of training; however, this was not always aligned to the specific needs of people using the service. We identified gaps in training relating to Parkinson's disease and not all staff had completed training relevant to the needs of people they supported, positive behaviour support and diabetes care. The provider had assured us training would be completed by staff by September 2026.
Some aspects of medicines management required improvement. We found inconsistencies in the administration of time-critical medicines, some staff did not have sufficient knowledge of specific administration requirements, and records did not always demonstrate robust arrangements where people chose to take medicines independently. We also identified issues relating to the management of prescribed pain-relief patches. Following the inspection, the registered manager provided assurances action had been taken to address the issues identified and strengthen medicines management practices.
Although the provider had a shared vision for the service and had taken action to address previously identified staffing concerns, governance systems had not always been effective in identifying and addressing issues relating to medicines management, incident oversight and staff training. As a result, some quality assurance processes required further strengthening to ensure risks and areas for improvement were consistently identified, monitored and acted upon in a timely manner. However, the provider welcomed the feedback provided during the inspection and recognised opportunities to strengthen their oversight. The provider acted positively on this feedback and were committed to further improving the quality and consistency of the service. They will continue to update us on implementation of improved systems.