Updated 4 April 2025
Date of Assessment: 24 and 28 April 2025. We received new information from the provider following the assessment visits, so we returned for a third day on the 28 May 2025. This assessment was prompted in part due to concerns raised around the quality of care people received, staff conduct, and staffing levels. The service was last inspected 14 December 2021 (published 24 December 2021). The service is a residential care home for up to 36 older people. At the time of assessment there were 35 older people living at the home, some of whom were living with dementia.
We identified 3 breaches of regulation relating to receiving safe care and treatment, staffing, and governance of the service. Governance processes required improvement as audits had not always identified the concerns we found. Documentation around consent procedures needed to improve to ensure people were given as much opportunity as possible to participate in their care and make choices.
Staffing levels were not always consistent, and improvement was needed to ensure people were always safe. Several staff told us they were tired as they often worked below allocated staffing levels. Recruitment processes required more robust oversight to ensure staff records were checked and any gaps identified.
The provider did not always have guidance in place for staff to monitor and support people with identified risks, which included falls and bowel management. Staff received training relevant to their role and they understood their responsibility to protect people from abuse. However, some staff did not know who to contact outside of the service to raise concerns externally.
Some improvements were necessary to ensure staff understood equality, diversity and human rights in practice, as this had not always been the case.
People received their prescribed medicines as directed, however, some improvements were required to ensure safe storage, and protocols for medicines used ‘as required’ Facilities were clean and well-maintained.
The registered manager and provider were responsive to our findings and promptly implemented an action plan to begin making the necessary improvements.
The majority of staff spoke positively about the registered manager, but some staff told us they did not always feel valued or supported. We observed kind and caring interactions between staff and people living in the service. Staff knew people well which helped to provide person-centred care.
The overall rating for the service has changed from ‘good’, to ‘requires improvement’ at this assessment. We have asked the provider for an action plan in response to the concerns found at this assessment. In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/ or appeals have been concluded.