During an assessment under our new approach
Date of Assessment: 10 and 12 June 2026.
We completed this assessment as part of our regulatory activity, taking into consideration the length of time since the service's previous inspection. At the time of our inspection, there were 25 people using the service. The service did not have a registered manager although a person had been appointed as home manager and was in the process of registering.
We found that the provider was in breach of regulation in relation to consent to care, safe care and treatment and good governance.
Safeguarding concerns were not consistently tracked through to outcomes, learning and closure. Risks to people’s health and safety were not always comprehensively assessed or supported by clear guidance. Environmental risks, including falls, burns, scalds and fire risks, were not consistently identified or controlled. Staffing levels were sufficient, but staff did not always have the knowledge, training and competency required to meet people’s individual needs related to their health conditions. Infection risks were not consistently assessed, monitored or acted upon. Medicines were not always stored, administered or monitored safely.
People’s health and care needs were not always accurately assessed or reflected in consistent care plans and guidance. Prescribed diets, nutrition, hydration and other evidence-based interventions were not consistently understood or delivered. Information was not always accurately shared between services and teams. The provider did not consistently monitor whether planned care was delivered or whether clinical outcomes and risks improved. Consent, capacity and best-interest processes were not consistently completed where restrictive practices or care arrangements required them.
Information provided to people was not always complete, accurate or securely managed. The provider did not consistently remove barriers to people accessing activities and experiences important to them. End-of-life wishes and future care planning were not consistently explored or recorded in sufficient detail.
Leaders did not always demonstrate sufficient knowledge of their regulatory responsibilities or robust oversight of recruitment. Governance systems were ineffective. Audits did not reliably identify concerns found during our inspection and identified actions were not consistently allocated, completed, reviewed or signed off.
Overall, people’s experiences were predominantly positive. People and relatives described staff who were caring, approachable and responsive, and who supported dignity, choice, independence and individual preferences. However, the concerns identified through our assessment showed that these positive experiences were not always underpinned by sufficiently robust systems to ensure people’s assessed health, safety, consent and treatment needs were consistently identified, recorded and managed.
We have asked the provider for an action plan in response to the concerns identified at this assessment relating to person-centred care, dignity and respect, consent to care and treatment, and staffing.
In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.