Our current view of the service
Updated
3 October 2025
Date of Assessment: 20 October 2025 to 5 November 2025
The service is a residential home providing support to older people. Some people lived with dementia. At the last inspection, we identified breaches of regulation in relation to staff training, mental capacity and governance. At this inspection, we found improvements had been made.
The provider was previously in breach of the legal regulations in relation to safe care and treatment, need for consent, staffing and good governance. Improvements were found at this assessment and the provider was no longer in breach of these regulations.
The provider was actively working to strengthen governance systems, improve medication procedures, and clarify staff roles and responsibilities to ensure greater accountability and consistency. These improvements were still embedding, and the newly appointed management team required time to familiarise themselves with policies, procedures, and systems.
Medication processes needed clearer guidance, more detailed records, and consistent application of protocols. The provider responded promptly, scheduling additional medication training and implementing measures to improve stock control and record-keeping. Governance arrangements, including risk registers and quality monitoring, were in place but not always applied consistently, and defined accountability was being clarified to support better communication and decision-making. These areas for improvement did not impact negatively on people’s wellbeing.
Despite these areas for development, the service demonstrated strong person-centred care. Staff listened to people, adapted care as needs changed, and involved individuals and their families in planning. People told us they felt informed and supported. Care was tailored to individual needs and responsive to feedback.
Staff treated people with kindness and respect, promoting dignity and independence. New staff received thorough induction and ongoing training, and staffing levels were regularly reviewed to ensure safe and effective care. Leadership used audits and incident data to drive improvement, and we saw evidence of progress. The provider maintained a regular presence in the home, offering guidance and support to ensure the team had the resources and confidence to succeed.
People's experience of the service
Updated
3 October 2025
People experienced safe, caring and person-centred support, with the home undergoing positive improvements under new leadership. The provider was open, present in the service and responsive to concerns, which helped create a culture where staff felt confident to speak up and issues were addressed quickly. This meant that when risks, such as infection control problems or medication error, were identified, people saw swift action and improvements.
Staff worked with people to manage risks in a way that balanced safety with independence. Health needs were monitored well, and strong communication with GPs, nurses and therapists meant people experienced smooth transitions and consistent care. Safeguarding was well understood, and external professionals felt people were safe. Some inconsistencies in infection control and medicines management had the potential to affect people, but the provider acted promptly, and systems were being strengthened.
People were supported by kind and motivated staff, including team members who were still adjusting to new systems and roles. Staffing levels were reviewed regularly, call bells were answered promptly, and new staff received thorough inductions. People felt their needs were met quickly and respectfully. We observed staff interacting with people positively, with kindness and compassion, particularly during mealtimes and activities.
Care was based on thorough assessments, evidence-based practice and a strong understanding of each person’s preferences and backgrounds. People enjoyed meaningful activities, community involvement and opportunities to stay active, which supported wellbeing. Staff consistently treated people with dignity, empathy and respect.
People and their families were involved in decisions about care, and feedback led to improvements, such as reminders to keep drinks within people’s reach. Future planning, including end-of-life wishes, was handled sensitively.
Leaders were compassionate, visible and committed to improving governance and accountability. While some systems were still embedding, the provider had already taken steps to strengthen oversight and support staff. People benefited from a stable, improving service with strong partnerships across health and community organisations.