Updated 9 June 2025
Date of assessment: 9 July to 5 August 2025. The service is a residential care home providing support to older people living with dementia, mental health conditions, physical disabilities and sensory impairments. At the time of the assessment 27 people were living at the home.
The assessment was completed to follow up on breaches of regulation identified at our last inspection, to see if improvements had been made.
We found medicines were not being managed safely, this included issues with missed medication, stock control and record keeping. The provider did not have an effective learning culture, with no evidence analysis was completed and lessons learned. Where people lacked capacity, we saw no evidence decisions had been made following the best interest process. We were not assured people were receiving modified diets in line with guidance, as information in care files was contradictory and food logs lacked detail. Although the majority of safety checks had been completed, issues with window restrictors and the securing of freestanding furniture had not been picked up. Staff received regular supervision, however, training in some topics to ensure people’s needs could be met was not currently provided. Enough staff were deployed to keep people safe. Risk assessments lacked detail, however, staff knew people well and how to manage key risks. The provider and care staff worked with healthcare partners to establish and maintain safe systems of care, and ensure continuity of care when people were admitted to hospital. The home was clean with effective infection control processes in place.
The providers governance processes were not robust, with audits and monitoring not identifying any of the issues we noted during the assessment. There was not a culture of continuous improvement, with a lack of action and improvement plans in place. Processes to seek people and relatives’ views were in place, but feedback received was not always analysed or acted upon. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. Leaders were reported to be friendly, helpful and to listen. People felt supported and that their issues were taken on board and addressed.
The provider was previously in breach of legal regulations in relation to medicines management and governance processes. Improvements were not found at this assessment, and the provider remained in breach of these regulations. At this assessment, the provider was also found to be in breach of the legal regulations relating to the adherence to the Mental Capacity Act, nutrition and hydration, premises and equipment and staff training.
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