During an assessment under our new approach
Date of assessment: 24 March 2026 to 2 April 2026.
We started the assessment on 24 March 2026 and visited the service on 24 March 2026 and 25 March 2026. We reviewed documents and had follow up contact with the provider, including a further onsite visit on 2 April 2026. We finished the assessment on 2 April 2026.
The service is a care home providing accommodation, nursing, and personal care for up to 6 people. At the time of our assessment there were 5 younger adults living at the service. A registered manager was in place. The registered manager is registered with the Care Quality Commission (CQC) and is legally responsible for ensuring the service is compliant with legal and regulatory requirements.
We carried out a comprehensive assessment of the service due to the length of time since our last rating. Our last assessment for this service was in 2017, and we rated the service Good. At this assessment, the service had remained Good overall. However, we have rated the key question of effective as requires improvement.
This inspection was conducted by one inspector and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service. We spoke with five people who live at the service, four relatives, and eight staff including support staff, therapy staff, a registered nurse, the registered manager, quality manager, quality lead and performance director.
The provider had a positive culture of safety, based on openness and honesty. Staff completed safeguarding training and knew how to raise concerns. The service was clean, tidy and maintained to a high standard. There were enough staff deployed to keep people safe and meet their specific needs and we found staff had been recruited in line with safer recruitment practices. We found staff were knowledgeable about people’s individual needs and how to keep them safe.
Improvements were required in the overall co‑ordination of the service to improve our findings in relation to governance. For example, although individual staff members were responsible for updating different elements of people’s care plans and risk assessments, no single staff member had oversight of the full process. This lack of clear ownership meant that some care records, including care plans and risk mitigation plans, were not consistently updated or aligned, which increased the risk of gaps in communication and care delivery. We also found some improvements were required in relation to medicines administration.
Although the feedback we received was positive about the leadership of the service, we found that the leadership had not always been consistent in relation to governance, and some improvements were required. Staff told us the manager was, “Brilliant, approachable, helpful.” Another staff member told us the manager was, “Interested interest in [them] as a person and supportive.” People and relatives told us, the registered manager was, “Not good – they [manager] was brilliant,” “I know the manager and they are approachable,” and, “I know who the manager is, the service is well managed, nothing could be done differently to improve it.”
We returned to the service before the end of the assessment and found immediate improvements had been made in relation to all aspects of feedback we had shared with the provider, including medicines, care planning, risk mitigation, mental capacity assessment and best interest decision, personal emergency evacuation plans and hospital grab sheets. We were assured that although we had highlighted shortfalls the provider had reflected and used our findings as a learning opportunity to take appropriate action to make immediate improvements.