During an assessment under our new approach
About the service
Smalley Hall Care Home is a residential care home, providing accommodation and personal care for up to 26 people. At the time of our assessment, there were 21 people using the service. The building has 2 floors, and people had access to communal lounges and a secure outdoor space.
Who the service is for
The service supports older people, people with physical disabilities and people living with dementia.
Key findings
We carried out this assessment on 30 September 2026. This service was previously rated as good. We carried out this assessment to confirm whether the rating of good remains accurate. This report does not provide detailed information on areas where we found practice continues to meet a good standard. Instead, our findings focus on any areas where the service needs to improve or where we found exceptional practice.
There was a strong learning culture within the service. When things went wrong, staff and leaders understood their reporting responsibilities. Accidents and incidents were regularly reviewed and analysed to identify learning and actions to improve safety. The registered manager told us, “We are always looking at what’s needed to improve safety.
Safeguarding was taken seriously, with clear policies, procedures and training in place to support staff in recognising and responding to safeguarding concerns appropriately.
Risks to people were identified and robustly assessed, involving people and those important to them. Care plans provided clear guidance for staff on how to support people safely, and we observed staff providing care in line with individual guidance. For example, when supporting a person who displayed some signs of distress. Staff and leaders understood positive risk taking in promoting people’s independence and supporting them to make informed choices.
People were cared for in a safe, clean and well-maintained environment. Equipment and accessibility aids people needed to keep safe were available and kept in good working order. Regular health and safety checks on the premises and equipment were carried out. The service had recently undergone a refurbishment, which had been completed to a high standard.
People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that staff and management worked within the MCA. DoLS authorisations were appropriately applied for and overseen. People were not subject to unlawful or excessive restrictions they had choice, control and freedom over their lives.
Medicines were managed safely and people received their medicines as prescribed.
There was enough staff to keep people safe. Staff had received training to carry out their roles. Staff were committed to developing their skills and progressing within the organisation, and some told us they were keen to see further opportunities to support their career development.
Nationally recognised tools were used effectively to monitor outcomes for people, for example tools to monitor skin integrity, or risk of malnutrition. Staff worked well with healthcare professionals, and records showed advice and recommendations were promptly sought and followed. A visiting professional shared, “Staff know people so well, they would pick up any changes before I do but they will always, always, mention it, they take time to get to know them.”
Care records reflected people’s diverse needs, preferences and life histories. We received consistent feedback that staff knew people well and people’s choices in how they wished to be supported were respected. For example, preference of gender of staff supporting them.
The service was well-led. There was a positive culture within the service, with the provider’s values understood and shared by staff and leaders. Staff and leaders were proud to work at Smalley Hall Care Home and were motivated by providing good quality, person centred care for people. One staff told us, “We want to provide the best care for our residents.
There were robust governance systems in place to support quality improvement and risk oversight. The registered manager was supported by the provider’s compliance team. The registered manager told us, “If there is an area we know we need to focus on more the provider will tweak the audit so we can add more focus. For example, following a medicines error.” Audits and checks were data driven, and created clear actions where issues were identified. These were reviewed to ensure improvements were made. Feedback was actively sought and analysed to shape the service. This demonstrated a commitment to continuous learning and improvement.