Updated 14 January 2026
Date of assessment 20 February to 10 April 2025. We conducted an on-site assessment visit on 17 and 18 March 2025 in response to concerns.
We rated the service as Good.
The service demonstrated a strong safety culture, with staff actively reporting incidents and learning from them. Safeguarding was well managed with 96% training compliance, medicines were handled safely, and care transitions were smooth. Patients and families consistently described staff as compassionate and responsive, and innovative therapies such as harp music and specialist pain management enhanced patient experience.
However, staff did not always assess or manage environmental and clinical risks effectively. Cleaning records were not consistently maintained, with some areas observed to have dust. The deteriorating patient’s policy lacked clear escalation guidance, and nursing staff training compliance for sepsis was only 88%, which breached regulatory requirements. Governance systems did not always ensure policies were aligned with national standards.
We assessed a small number of quality statements from the safe, effective, caring, responsive and well-led key questions and found areas of good practice and concerns. The scores for these areas have been combined with scores based on the key question ratings from the last inspection.
Though the assessment of these 5 quality statements indicated areas of concern since the last inspection, our overall rating remains good.
We found 1 breach of regulation relating to risk management. We requested an action plan following publication of the final report.