During an assessment under our new approach
This assessment was carried out on 25 March 2026 to 20 April 2026, with onsite visits on 25 and 26 March, and 20 April 2026. We carried out this inspection following risk-based concerns we received about the service. The service provides accommodation and personal care to adults over 65, adults under 65, people with physical disabilities and people with sensory impairments.
At this assessment, the overall rating is Requires Improvement. This is because leaders did not always ensure systems and processes were effective in identifying risks, embedding learning or driving improvement. Governance arrangements were not consistently robust, and leaders did not always act on information about risk, performance and outcomes.
We found shortfalls in how the provider assessed, monitored and responded to people’s changing needs. Staff did not always act promptly on professional advice or updated clinical information, including following changes in people’s health needs and medicines after hospital discharge. This increased the risk that people did not always receive safe, timely and coordinated care.
Care plans and records were not always complete or up to date, which reduced oversight and increased the risk that care was not consistently delivered in line with people’s needs. Leaders did not always ensure learning from incidents, feedback or audits was embedded into practice to reduce future risk.
Leadership and culture were not consistently open or inclusive. Staff told us they did not always feel safe to speak up and were not confident concerns would lead to change. The provider did not always work effectively with partners, which reduced assurance that care was coordinated when people’s needs changed.
However, people and relatives gave positive feedback about staff, and we observed kind and respectful interactions. Staff understood people well and supported their day-to-day needs, including access to healthcare and promoting independence in some areas.
We found 2 breaches of regulation relating to safe care and treatment and governance.
We have asked the provider for an action plan in response to the concerns found at this assessment.