During an assessment under our new approach
Date of assessment: 12 August to 22 September 2025. This was a responsive inspection of all 5 key questions triggered by our ongoing monitoring of the service. The service is a residential care home for up to 8 people, providing support for older people who may be living with dementia. At the time of the inspection there were 4 people living at the service. In addition there was 1 person staying at the home for a short stay, and 1 person accessing day care.
We found improvements were needed in some aspects of the service for people’s safety. These included, managing risks with the environment, medicines, safe recruitment, staff training, and governance.
Risks to the environment had not always been effectively assessed, including fire and legionella safety. People’s medicines were not always safely stored and administered. The registered manager had not always shared information of concern appropriately, as they did not always notify CQC of events, as required.
Staff did not always have the training they needed to keep people safe. For example, 1 member of staff did not have up to date medicines training.
Management oversight systems had not been used effectively to assess, monitor and improve the safety of the service and had not identified the shortfalls we found during the inspection.
However, the provider and registered manager were responsive to concerns and took some action to mitigate risk. Staff, people, and their relatives spoke positively about the service and leaders, who were visible within the service and who actively engaged with them.
We observed there were sufficient staff available to support people who knew people’s needs and preferences enabling them to support people in a person-centred way. Staff understood their responsibility to safeguard people from abuse and how to report concerns.
We found 1 breach of the legal regulations in relation to governance.
We have asked the provider for an action plan in response to the concerns found at this assessment.