Our current view of the service
Updated
2 April 2026
Date of assessment: 30 April 2026 to 1 May 2026
We inspected this service due to concerns identified around risk management, care planning, and mitigation of foreseeable harm, particularly around unexplained injuries, falls prevention, clinical monitoring and environmental safety. Since the last assessment the provider has changed.
We found the provider was in breach of the legal regulation relating to consent, safe care and treatment, good governance and staffing.
Governance systems were not consistently effective in identifying, assessing and mitigating risks to people. We found repeated shortfalls across key areas including medicines management, risk assessment and management, safeguarding oversight, staffing deployment, infection prevention and control, and environmental safety. Although some risks had been identified through internal processes, we found these were not always acted upon in a timely or effective way, resulting in continued exposure to potential harm for people.
Systems for monitoring quality and safety were not robust. Audits and quality assurance processes did not consistently identify or address shortfalls, and where issues were identified, there was limited evidence of sustained improvement. Lessons learned were not consistently embedded into practice, and action plans did not always demonstrate clear completion or sign-off. This meant the provider could not demonstrate effective oversight of the quality and safety of the service.
We found that staffing arrangements were not always effectively planned or deployed to meet people’s needs. Monitoring of staffing effectiveness and dependency levels did not always take account of call bell demand, incident trends or periods of increased risk. This resulted in inconsistent assurance that sufficient staff were always available to meet people’s needs in a timely way.
Although some immediate actions were taken during and following the inspection in response to identified risks, these were at an early stage of implementation and had not yet been embedded or tested for effectiveness. As a result, the provider could not demonstrate sustained improvement in the quality and safety of the service.
We have asked the provider for an action plan in response to the concerns identified at this assessment relating to consent, safe care and treatment and staffing.
In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.
People's experience of the service
Updated
2 April 2026
People and relatives provided predominantly positive feedback about their experience of care at the service. They consistently described staff as kind, caring and compassionate, and told us staff treated people with dignity and respect in day-to-day interactions. People told us they felt well supported by staff who knew them well and responded in a friendly and respectful manner.
People generally reported feeling safe living at the service. Relatives also described positive experiences of care, including support with personal care and attention to maintaining people’s appearance and dignity. Some relatives highlighted that staff paid attention to small but important aspects of care that contributed to people’s wellbeing and comfort. This demonstrated that, for many people, day-to-day care was experienced positively.
People told us they were supported to make choices about their daily lives, including decisions about personal care, meals, and how they spent their time. We observed staff offering choices and supporting people to make day-to-day decisions. This demonstrated that people were generally supported to exercise control over their daily routines.
However, people’s experience was not consistently positive across all aspects of care. Some people and relatives raised concerns about staffing levels and delays in call bell responses, particularly at night and in the mornings. People told us that call bells were not always answered promptly, and relatives described similar experiences. During the inspection, we also observed delays in staff responding to people in distress. This meant that some people did not always receive timely support when they needed it.
People also experienced variation in access to meaningful activities and engagement. Those who were more mobile generally had access to a wider range of activities, while people receiving care in bed had fewer recorded opportunities for stimulation or engagement. Some relatives expressed concerns that opportunities were not always equally available to all people. This demonstrated inconsistency in how people’s social and emotional needs were supported.
People’s experiences of communication and involvement were mixed. While some people and relatives told us they were kept informed and involved in decisions, others told us they were less clear about care plans or changes in care. This indicated that involvement in care planning was not consistently embedded across the service.
Despite these inconsistencies, many people told us they felt staff knew them well and understood their individual needs. People described positive relationships with staff and told us they felt well cared for in day-to-day interactions. This demonstrated that, overall, people experienced kind and respectful care, although the quality and consistency of their experience varied across different aspects of the service.