Updated 15 August 2025
We carried out this inspection on 10 September 2025 in response to ongoing concerns about the service. Since our last inspection in April 2024, when the service was rated good overall, we have received information of concern from multiple sources.
In April 2025 changes were made to the leadership team by the provider in response to concerns received. The provider also took steps to provide additional management oversight to address the concerns about the leadership and culture in the home. A new manager had started shortly before this inspection. At the inspection we assessed the impact of these leadership changes and reviewed whether people were receiving safe, effective care.
We assessed 21 quality statements across the five key questions: safe, effective, caring, responsive, and well-led.
We identified one breach of the regulations in relation to the governance and oversight at the service.
There were shortfalls in effectiveness of the governance and oversight of the service. The systems in place did not identify the shortfalls found in environmental safety checks and the recording of consent in relation to CCTV. People’s future care planning preferences were not consistently recorded . There were shortfalls in the staff’s skills and knowledge in relation to supporting people to eat safely to mitigate the risk of choking. These identified shortfalls had not impacted on people’s safety, health and well being but had not been identified by the provider. However, we found an improved understanding and recording in relation to obtaining and recording people’s consent in line with the Mental Capacity Act 2005.
The provider was responsive, and immediate action was taken to address the risks identified. We have asked the provider for an action plan in response to the concerns found at this assessment. We will work alongside the provider and local authority to monitor progress.