During an assessment under our new approach
Date of inspections: 29 July to 10 August 2026
Moss Cottage is a care home providing personal and nursing care to 33 older adults, younger adults, people with physical disabilities and people living with dementia at the time of the inspection. The service can support up to 34 people. The home has communal areas, including lounge and dining area and communal bathrooms. There are single bedrooms across two floors, some of which have en-suite facilities.
This inspection was undertaken to follow up on concerns raised by the coroner’s office following a death of a person living at the home.
At this inspection we found 3 breaches of regulation. These related to concerns about the management of risk and medicines, how people received care that was personalised and met their need, and how the provider ensured governance of the safety of the service.
People were not always protected from avoidable harm because systems for managing risks, medicines, admissions and staffing were not consistently effective. We found concerns relating to medicines management, including storage and ensuring medicines were given at appropriate times. Information about people’s current needs was not always accurate or detailed, and there was a high use of agency staff who did not know people well. People and families generally felt safe and permanent staff were suitably recruited and trained. The provider took prompt action when concerns were identified, but improvements were needed to ensure risks were consistently recognised, monitored and managed.
People’s experiences of how they were cared for varied. Overall, people felt the permanent staff knew them and were kind and caring. However, not everyone felt their choices and preferences were respected, and how quickly staff responded to peoples request for support varied.
People were supported to access healthcare services and regular staff generally understood people's needs. However, care plans, risk assessments and records were not always completed promptly or reflected current needs, and professional guidance was not always incorporated into care records. People generally enjoyed their food and were being supported to remain hydrated. Wounds were managed and appeared stable, or improving, although improvements were needed to some areas of documentation, including when people first arrived at the home.
People’s needs were not always met through person-centred care and support. Care plans lacked detailed personalised information, records were not always consistent, and some people reported feeling not fully involved in decisions about their care. The high use of agency staff affected the continuity and consistency of support. The provider had begun reviewing activities provision and ongoing work was underway to improve care planning. Further improvements were needed to ensure care was tailored to people's preferences, wishes and changing needs, including when planning for the future.
Leadership and governance arrangements were not always effective in ensuring the delivery of high-quality, person-centred care. While the provider had identified areas for improvement and was actively responding to concerns, the auditing systems had not consistently identified and addressed the issues found during the assessment. The absence of a registered manager, and reliance on agency staff impacted upon oversight and sustainability.
We have asked the provider for an action plan in response to the concerns found at this assessment.