Our current view of the service
Updated
12 March 2026
Date of assessment: 15 April to 7 May 2026
This inspection was undertaken in response to identified risks arising from individual cases and emerging patterns of concern. The findings identified during the inspection highlighted further areas of risk, requiring an expanded and more detailed review.
The service was not providing consistently good care. Weaknesses in care planning and risk management meant people were exposed to avoidable harm, as changes in need were not always identified or acted on promptly.
Medicines were not always managed safely, with records showing missed doses, delays in administering time‑critical medicines which increased the risk of harm.
Systems intended to monitor quality and safety were in place but were not used effectively to highlight concerns or trigger timely action. As a result, learning from incidents, audits and feedback did not consistently lead to improvement. Leadership and governance arrangements lacked stability and effective oversight, which limited accountability when issues were identified.
Staffing pressures further affected the service’s ability to deliver safe and consistent care, and staff were not always supported through effective supervision or development.
Although the provider had begun to take steps to address leadership, governance and workforce concerns, these actions were at an early stage and had not yet resulted in sustained improvement at the time of inspection.
The provider was in breach of the legal regulations relating to safe care and treatment and good governance.
People's experience of the service
Updated
12 March 2026
People’s experiences were mixed and not consistently positive. While some people and their relatives described kind and caring interactions with individual staff, this was not always supported by reliable systems, staffing or continuity. As a result, people’s experiences often depended on who was on duty rather than being consistently shaped by clear, person‑centred care planning.
People were not always supported in a timely or responsive way. Relatives reported delays in staff responding to requests for help, supporting personal care or addressing immediate needs. Some people remained in bed longer than expected, were not assisted promptly when distressed or unwell, or experienced delays in accessing care. This affected people’s comfort, dignity and sense of safety.
Relatives frequently described a lack of clear communication and involvement. Many said they were not routinely involved in care planning or decisions, even when people’s needs changed or when they were approaching the end of their lives. Some described having to repeatedly chase information or raise concerns before action was taken, which reduced confidence that the service was open or responsive.
People’s individuality was not always reflected in care delivery. Information about preferences, routines and what mattered most was not consistently used to guide daily care, leading to variation in experiences. Opportunities for meaningful activity were limited for some people, particularly those requiring higher levels of support or spending time in bed, which contributed to boredom and isolation.
People with higher dependency, mobility or communication needs were more likely to experience delays or unmet needs during periods of staffing pressure.