Updated 13 August 2025
Date of assessment: 10 September to 6 October 2025. The service is a residential care home, providing support to older people and younger adults. This assessment was undertaken due to the age of the previous rating, as it was approaching 6 years since we last inspected.
At this assessment the provider was in breach of 6 legal regulations. These where in relation to person-centred care, seeking consent and adhering to the Mental Capacity Act 2015, management of medicines, management of people’s modified dietary needs, ensuring premises and equipment were safe, governance processes, staff training and support.
Some care plans viewed contained a lack of person-centred information, insufficient details about people’s needs and how to meet these, as well as contradictory information about their abilities and care needs. Care records did not always contain signed consent forms to ensure people were consenting to their care and support. Where people lacked capacity to consent, the best interest process was not being used to support decision making. Medicines were not always managed safely, and where people required a modified diet, we were not assured these were being provided in line with assessed needs, which increased the risk of people choking or aspirating. Required checks to ensure equipment and the environment were safe had not all been completed fully or in line with guidance. The provider’s audit and governance processes were not robust. Audits had not identified the issues we found on assessment, and where they had identified shortfalls, actions had not been taken timely. Staff had not been provided with sufficient training and support to ensure they could carry out their roles safely and effectively. Completion rates for all training sessions were very low. Staff supervision had only commenced in May 2025, when the current manager commenced employment.
Resident meetings had been recently introduced to involve people in the running of the home and capture their views. The current manager and assistant manager were open and honest throughout the assessment process. They acknowledged current shortfalls in practice, which they said had been inherited when they commenced their roles. They took action during the assessment process and afterwards to make improvements and mitigate risks.