During an assessment under our new approach
About the service
The service is a care home. There were 63 people using the service at the time of the assessment.
Who the service is for
The service supports older people and people living with dementia.
Key findingsWe carried out this assessment on 15 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.
Staff knew how to recognise signs of abuse and discrimination and understood their responsibility to report any concerns. The management team worked with the local authority safeguarding team to protect people from abuse and risk of harm. Where concerns had been identified, action had been taken to reduce the risk of it happening again. There was a learning culture within the service. Accidents and incidents had been recorded and analysed to identify any patterns and trends. Action had been taken to reduce the risk of potential harm including changing the bed and introducing the use of hip protectors when people were at risk of falls. Staff understood their role in supporting people to stay safe such as when mobilising.
People were supported to make choices and decisions. We observed people being given choices and making their own decisions which staff respected. When people had capacity to make complex decisions and manage their own health appointments, they were encouraged to do this, including contacting the GP or hospital independently. When people had been assessed as not having capacity to make complex decisions for themselves, these were made in their best interests. Staff knew who could legally be involved in making decisions for people.
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. We observed people mobilising around the service including into the garden when they wished.
Potential risks to people’s health and welfare had been assessed and there was clear guidance for staff about how to support people safely and what to do if people became unwell. Regular checks had been completed on equipment people used and the environment and any shortfalls were addressed. Environment risk assessments had been completed apart from heated towel rails in some rooms. The registered manager confirmed the action taken following the assessment to reduce the risk of burns.
Staff had been recruited safely, and checks had been completed to ensure they had the skills to meet people’s needs. New staff completed an induction, which included working with more experienced staff. All staff received training to support people safely including catering staff so they could recognise when people were unwell. Staff training needs were reviewed regularly and new courses added. For example, staff received additional training to support people with Parkinson’s disease, as more people were being admitted to the service with the disease.
There were enough staff to meet people’s needs. There were some staff vacancies at the time of the assessment, but staff were working extra hours to cover these shortfalls. The vacancies were being advertised, and these vacancies had not impacted on people’s care and support.
Medicines were generally managed safely. People received their medicines as prescribed but there had been instances where the number of tablets on the computer system did not match those available. The management team investigated the concerns and found administrative errors where staff had not completed the computer records correctly. An action plan has been developed to reduce the risk of this happening again.
The management team completed assessments before people moved into the service to ensure staff could meet their needs. People’s health needs were assessed using recognised tools such as the Malnutrition Universal Screening Tool (MUST). These tools helped staff make decisions about what action to take and when to refer to health professionals.
People, staff and relatives were asked for their views about the service. The management team responded to any concerns raised, ensuring people and relatives were happy with any changes made and action taken.Staff told us they were supported by the registered manager and their team. Staff received regular supervisions and appraisals. Staff told us they were supported if they made a mistake and it was used as a learning experience. Staff were given the opportunity to become a ‘Champion’ for their area of interest such as Parkinson’s Disease, to support learning and skills.
Regular checks were completed on all areas of the service, including checks on the environment and records. The registered manager had access to the CCTV in communal areas on their laptop and checked these regularly when they were not in the service. When shortfalls were identified action plans were put in place to address these and were monitored to ensure improvements were sustained.