During an assessment under our new approach
We carried out this assessment on 29 September to 6 October 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 were supported by safely recruited staff who received an induction, supervision, and ongoing training in their roles. There was a stable and consistent staff team. Staff knew people well and had developed positive relationships with people living at the home. A staff member said, “We are well staffed.”
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 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. Staff gained consent from people and respected people’s choices. Mental capacity assessments and best interest decisions were conducted where appropriate. The provider acknowledged where some improvements were required to ensure mental capacity assessments were decision specific and utilised the best interest decision making process to explore the least restrictive options, before a decision was reached.
People’s rooms were personalised and reflected their support needs. Regular checks on fire safety equipment and procedures were completed. People’s medicines were managed and administered safely. Risks to people were identified and guidance directed staff how to manage these. A staff member said, “Risks are detailed.” Staff knew how to identify and report any safeguarding concerns, accidents, or incidents. Communication systems ensured staff were updated with any changes in people’s care and support needs, which included a detailed verbal and written handover. Staff said, “Communication is good,” and “We get a good handover with written notes as well.”
People’s care plans were person centred and described clearly how people wished to be supported. Care plans included people’s likes and dislikes. Care plans guided staff how to positively support people and minimise distress and discomfort. Care plans detailed how staff should respond to observed behaviours. Regular reviews of people’s care and support were conducted. A keyworker system supported this. A relative said, “I’m always invited to care reviews.” People were supported with individualised goals. People had support to attend appointments in regard to their mental and physical health.
Feedback was sought from people, relatives and professionals and actions taken in response. Relatives told us they felt comfortable in raising concerns. A staff member said, “We can speak up. I would raise anything.”
The service’s vision and aims were explained on the provider’s website. Organisational values were displayed in the service and included in the provider’s recruitment process. A staff member said the service, “Improved the quality of life for people.” Potential new staff visited the service so people could meet them and interactions could be observed. Staff told us they enjoyed working at the service and said they were valued and supported in their roles. A staff member said, “We work well as team.”
Staff and relatives spoke positively about how the home was led and managed. Staff said the registered manager was, “Approachable” and “Listened.” Governance systems assessed and monitored the quality and safety of the service. This included areas such as care plans, complaints, safeguarding concerns and accidents and incidents. Areas identified as needing actions taken to improve or develop were included in an action plan, which was regularly reviewed for progress.