During an assessment under our new approach
The service is a care home. There were 24 people using the service at the time of the assessment.
This service supports people living with dementia and people with physical disabilities.
We carried out this assessment on 20 August 2026. This service was previously rated as good. We carried out this assessment to confirm whether the rating of good remains accurate. This report does not provide detailed information on areas where we found practice continues to meet a good standard. Instead, our findings focus on any areas where the service needs to improve or where we found exceptional practice.
People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that staff and management team worked within the MCA. DoLS authorisations were appropriately applied for and overseen. People were not subject to unlawful or excessive restrictions they had choice, control and freedom over their lives.
People told us they felt safe and staff demonstrated a good understanding of safeguarding responsibilities, reporting procedures, and the requirements of the Mental Capacity Act and Deprivation of Liberty Safeguards. One staff member told us, “We support people who lack capacity, we complete a best interest decision, I can read their care plans and ask them, and we can talk to their family for likes and dislikes. Yes, people have choice and control.” Another staff member told us “We show people clothes so they can pick them, with food they have a choice. No restrictions at all, if someone wants a walk, or go into the garden. One [person] has bedrails, they have full capacity to agree to them, safety equipment is maintained and safe.” One relative told us, “[People] always get a choice like what to eat and what to do.”
People were involved in decisions about their care and support, with risks effectively assessed, monitored, and managed in a person-centred manner.
The home was safe, comfortable and supported by robust maintenance, health and safety, and fire safety processes, although further attention was needed to ensure secure storage arrangements were consistently maintained.
Robust recruitment processes, sufficient staffing levels, effective communication, and a well-trained workforce supported the delivery of safe care by staff who knew people well. Staff were supported through a positive learning culture, with comprehensive training, regular supervision, competency assessments, and effective knowledge sharing across the service.
Medicines were managed safely through effective auditing, staff competency assessments, appropriate storage arrangements, and strong management oversight.
People's needs were assessed using recognised tools and reflected in person-centred care plans that supported the delivery of individualised care, although recording of staff responses and outcomes following episodes of distress could be strengthened.
Care and treatment were delivered in line with current best practice and supported by effective multidisciplinary working, promoting positive health and wellbeing outcomes.
Effective monitoring systems enabled staff to identify changes in people's needs, maintain oversight of risks, and respond promptly to health concerns.
People were supported to make choices and retain control over their daily lives, with staff demonstrating a good understanding of consent, capacity, and best-interest decision-making.
People were treated with kindness, compassion, dignity and respect by staff who knew them well and promoted positive, trusting relationships.
Staff actively promoted people's independence, choice and control, ensuring individuals were involved in decisions about their care, routines and daily activities.
People received personalised care that reflected their preferences, interests and individual needs, with opportunities to maintain social connections and participate in meaningful activities.
The service actively sought feedback from people, relatives, staff and professionals and demonstrated a willingness to act on feedback to improve people's experiences.
People received inclusive and equitable care that recognised and respected their individual backgrounds, health needs and communication requirements.
The service was characterised by a warm, positive and person-centred culture, with visible leadership and staff who felt valued, supported and engaged.
Effective governance systems provided oversight of quality and safety, supported continuous improvement and service sustainability, although some record-keeping and filing arrangements could be further strengthened.
The service demonstrated a commitment to continuous learning and improvement through staff development, engagement with external organisations, responsive action planning, and effective use of feedback to drive positive change. One staff member told us, “There are always lessons to be learnt, we follow risk assessments, see what went wrong, how we can put it right, for example, if [person] fell and mobility deteriorated, we assess the equipment needed, if we need more staff to help with mobility, meet with the staff, check the care plans.” The registered manager told us, “We just recently were told we needed to have a thermometer in the meds cupboard, so we made sure changes were made and it was done. We send surveys for everyone and from the results see where to make improvements, where we need support and where we are excelling.”