Updated 24 April 2025
Date of Assessment: 17 and 25 September and 15 October 2025. The service is a residential care home providing support to older people. At the time of our inspection, there were 17 people living at the service.
The inspection was undertaken to follow up on the breaches of legal regulations identified at the last inspection in relation to risk management, the environment and governance. We found some improvements at this assessment, but the provider remained in breach of the regulations related to risk management and governance.
Not all areas of the home ensured people’s safety. This was because the provider had still not mitigated the risks of hot surfaces and hot water within bedrooms, ensuite facilities, and communal areas. Other risks people faced such as skin damage and malnutrition had not been adequately mitigated and information about falls people sustained had not been analyzed. This did not enable patterns and trends to be identified or used to minimize further occurrences.
There was not a formal system to determine staffing levels in line with people’s needs, and covering the staffing roster was at times a challenge. This meant there were times when there were staff shortages, which impacted on the delivery of person-centred care.
Medicines were not always safely managed. Topical creams and lotions in people’s bedrooms did not always match the prescription and there were expired items still in use. Staff had not always documented when they had applied topical creams or recorded the effectiveness of an ‘as required’ medicine.
Quality auditing systems were not always effective as shortfalls were not always being identified. The provider regularly visited the service but did not maintain a record of their visit. This did not demonstrate what the provider had assessed or how they expected the service to be further developed.
However, improvements had been made to the environment. An additional water tank had been added to the heating and hot water systems which meant better efficiency and a warm environment. Some rooms had been redecorated, including a bathroom and toilet which had contained widespread mold. Some carpets had been replaced, and there was new flooring in the conservatory. This had enabled a more pleasant environment for people.
Improvements had been made to cleanliness, and housekeeping staff had been deployed to work at weekends. This had ensured a more consistent approach to cleaning and enabled care staff to focus more on care provision.
The registered manager had focused on ensuring staff were up to date with their training and a new formal support and supervision system had been implemented. Staff were knowledgeable about what constituted abuse and said they would report any concerns. They were confident the registered manager would take any required action.
Staff had signed the medicine administration record when administering people’s medicines and personalised guidance was available for ‘as required’ medicines. People had their medicines regularly reviewed and positive relationships had been established with local health and social care professionals.
In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.
We have asked the provider for an action plan in response to the concerns found at this assessment.