Updated 15 May 2025
Date of Assessment: 20 May to 6 June 2025. The service is a care home providing support to older people, adults of all ages, providing personal care and nursing care, some of whom are living with dementia. The service is registered to support up to 36 people. At the time of this inspection, 31 people were using the service.
At the previous inspection, the service was rated as requires improvement and was in breach of regulation 17 good governance. Following this inspection, the overall rating has remained requires Improvement, and they continue to remain in breach regarding the governance of the service. We have also determined a breach in regulation 18 staffing.
This inspection was carried out in response to concerns raised about the safety and management of the home. As a result, we focused specifically on the safe and well-led quality statements.
The provider did not always demonstrate a good learning culture. Learning from lessons when things went wrong had not always been embedded, this had placed people at risk of harm. Governance systems were not always robust, which limited the provider’s ability to support continuous learning and delivering consistently good-quality care. While some environmental improvements were needed, the premises and equipment were generally clean, well-maintained, and suitable for people’s needs, with effective risk management in place. Staff had appropriate skills, qualifications, and experience; however, both staff and people reported additional staffing was necessary to provide person-centred, rather than task-focused, support. The provider ensured staff received ongoing training and regular appraisals, to support the delivery of high-quality care. However, we found medicines were not always managed effectively.
Staff knew how to raise concerns but told us they did not always feel heard and did not always feel supported by a ‘no-blame culture’. Staff mostly knew how to safeguard people from abuse.
Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible and supported staff to develop in their roles. Feedback from people, relatives and staff indicated shortages of staff. Although staff understood their roles and responsibilities, we observed them carrying out tasks outside of their designated roles, with staff frequently switching between duties not aligned with their core responsibilities.
We have asked the provider for an action plan in response to some of the concerns found at this assessment.