Updated 25 February 2025
Date of assessment: 17 – 19 March 2025. We needed to check compliance with the legal regulations following the previous assessment.
The service is a nursing home providing support to older people, people who may be living with dementia, and people with a physical disability.
Not enough improvement had been made and the provider continued to be in breach of the legal regulations regarding safe care and treatment, and good governance. We identified a new breach in staffing.
The provider did not review incidents to learn lessons effectively and did not make sure there were enough staff to meet people’s needs. Improvements were required to manage risks to people’s health, minimise the risk of abuse, and to manage medicines safely. Health and safety checks had been made on the environment.
The provider did not always make sure people’s health outcomes were monitored effectively, and improvements were required to make sure people were supported to live healthier lives. People were supported to eat and drink healthily. The provider followed safe procedures to make sure consent for care was obtained.
People were treated with kindness and compassion. Staff protected their privacy and dignity and knew people’s like and dislikes. People had choice in their care and friends and relatives were made to feel welcome.
People were mostly involved in decisions about their care. People knew how to give feedback and raise concerns. The service was easy to access. The provider supported people who were at the end of their lives well.
The provider did not have effective governance systems to manage the service, for example around monitoring of incidents. Improvements were not always made to people’s care following an incident. Although there was a schedule of audits, audits did not always identify issues to make sure that improvements were made. Staff felt supported, able to raise concerns and that they would be listened to.
We have asked the provider for an action plan in response to some of the concerns found at this inspection.
In instances where CQC have decided to take civil enforcement action against a provider, we will publish this information on our website after any representations and/ or appeals have been concluded.