Fort Horsted Care Home Ltd

Updated 2 April 2026

The inspection was carried out between 22 April 2026 and 18 May 2026. Fort Horsted Care Home is a care home with nursing supporting up to 30 older people, including people living with dementia, physical disabilities and complex health needs.

We carried out this inspection in response to concerns about safeguarding and managing risks for people and to follow up on an existing breach in relation to safe care and treatment from the previous inspection (report published 27 July 2022). Improvements were not found at this assessment, and the provider remained in breach of this regulation. We also identified a new breach in relation to good governance.

Risks for people had not always been well managed. Risk assessment and care planning quality was variable. Some records were detailed and person centred, however others lacked essential information, were not sufficiently personalised or were not consistently followed in staff practices. This placed people at risk of harm, particularly in relation to repositioning, hydration, nutrition and constipation management.

The provider had not always followed local safeguarding protocols. Accidents or incidents, including those which constituted possible safeguarding concerns, had not always been robustly reviewed with sufficient action to reduce future risks. Despite this, people and relatives consistently told us they felt safe living at the service and described staff as kind, respectful and caring.

Medicines continued to not always be managed safely. We identified some medicine management shortfalls, including missed opportunities to respond to constipation risks, medicines stock discrepancies and incomplete PRN (as required) medicine protocols.

Staffing levels were sufficient to meet people’s needs, and people told us staff responded when they needed support. However, at nighttime some people and relatives described delays at night, particularly when waiting for shared equipment. We observed positive, warm interactions during our site visit, with staff knowing people well, seeking consent before providing care and supporting people’s dignity and independence.

The environment had benefited from some refurbishment since the last inspection, with improved flooring and redecorated bedrooms. However, some areas such as cleaning standards, furniture condition and laundry processes required further improvement.

Leaders were visible, approachable and committed to improving the service. There was evidence of a more open culture, improved staff morale and increased governance activity. However, systems to ensure effective oversight were not always robust, including incident analysis, safeguarding notifications, care planning and delivery checks and audit follow-up.

We have asked the provider for an action plan in response to the concerns found at this assessment.

Updated 2 April 2026

People and relatives felt people were safe living at the service and said staff responded appropriately to accidents or changes in health. A person said, “I like it, I am happy, everyone (staff) is very helpful.”

Relatives told us their loved ones were well cared for and that staff understood people’s complex needs. They spoke positively about communication and involvement in care planning. A relative said, “I have seen all of [Person’s names] care plans… they are very detailed, nothing for me to question.”

People told us and we observed staff asking permission before providing care and respecting people’s dignity and privacy. Staff were observed and reported to encourage independence where possible, such as supporting people to feed themselves or make choices about food. Relatives spoke positively about staff relationships with people. They described staff as kind, friendly and patient, with several noting long-standing staff who knew people well. A relative said “There is a core group of staff who know [relative’ name] well – they are like family.” Families felt reassured about the care their loved ones received. A relative summarised their experience by saying “It has taken away a lot of stress from me – I don’t leave feeling guilty or concerned.”

People and relatives felt able to raise concerns and that their feedback was listened to and acted upon, with examples of equipment, environmental and care adjustments made following feedback.

However, some relatives highlighted areas for improvement, including housekeeping and laundry.