During an assessment under our new approach
Date of assessment: 20 and 22 October 2025. The service is a care home without nursing providing support to older people, younger adults and people living with dementia. At the time of assessment, 25 people were using the service. This is the first rating of the service since the registration. The assessment was prompted by concerns raised regarding people’s care and support, risk management, and staff culture. We found the provider was in breach of the legal regulations relating to the management of medicines, staffing, recruitment, duty of candour, record keeping and good governance. We discussed the issues and discrepancies with the management of the service, and they started making changes and improvements. At the time of our site visit, the registered manager was on leave and is no longer at the service. The registered manager and provider did not always ensure they used robust assurance systems and governance processes which operated across all levels of the service. They had not always ensured there were clear records of people’s care and treatment to effectively assess, monitor and mitigate any risks relating to the health, safety and welfare of people using the service and others. They did not always ensure safe management of medicines, recruitment, staffing and training. This meant people were at risk of harm and not receiving care they needed. The facilities and equipment were mostly clean and maintained for infection risks to be mitigated. However, the environment had not been developed to meet the needs of people living with dementia. The provider needed to review and improve staff deployment and how staff's training needs and skills were managed in order to meet people's specific needs. The provider did not demonstrate they maintained clear records to meet requirements of duty of candour. People did not always have meaningful activities and opportunities to pursue their interests in their local area with others. People’s relatives were involved in reviewing and planning their care. However, we were not assured the registered manager ensured people’s views and decisions were fully considered. We were not always assured the registered manager and staff were working together to ensure the risks of a closed culture were minimised so that people received support based on transparency, respect and a positive culture in the service. Staff did not always feel supported by the registered manager. Staff were not always encouraged to be actively involved in the development and continuous improvement of the service. The registered manager did not always lead by example. Staff told us how they protected people from abuse and how they would report incidents, accidents and other concerns. Staff had training on how to recognise and report abuse and they knew how to apply it. However, they did not feel confident issues would be addressed appropriately by the registered manager. Staff ensured people were protected from the risk of acquiring an infection during the provision of their care. Staff supported people to access different services and support from health and social care professionals to promote and achieve positive outcomes for people. Most staff understood the principles of good care and treatment. People’s rights around privacy and dignity were considered and respected. Staff told us they understood their responsibilities to raise concerns and report incidents or allegations of abuse. We have asked the provider for an action plan in response to the concerns found at this assessment.