During an assessment under our new approach
We conducted our inspection from 3 June 2025 to 7 July 2025. We inspected the service after receiving concerns in relation to safe care and treatment. We reviewed all 33-quality statements. During our inspection, we identified 3 breaches of regulation in relation to safe care and treatment, fit and proper persons employed, and good governance. You can find more details of our concerns in the quality statement findings.
The service is a care home which also provides nursing care to up to a maximum of 60 older persons, some of whom live with dementia. At the time of our inspection there were 49 people using the service.
Risk assessments did not contain sufficient information to guide staff to support people safely which put people at risk of harm.
All required pre-employment checks had not been completed to ensure only appropriate staff would be employed.
Medicines were not managed safely; for example, not all ‘when required’ medicines had protocols in place to guide staff how to administer these medicines safely.
Mental capacity assessments and best interest meetings took place; however, were insufficiently detailed to demonstrate people were always protected and empowered to make their own decisions.
The provider did not operate effective quality and risk monitoring systems and had not identified the shortfalls we found. They had therefore not taken prompt action to reduce the risk these shortfalls posed to people.
Staff were observed to be caring and treated people with kindness, dignity and respect. There was a full activity programme for people to take part in. People participated in decisions about their care. People knew how to give feedback and were confident the provider took it seriously and acted on it. The service was easy to access and worked to eliminate discrimination. People received fair and equal care and treatment.
Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, and supportive, helping staff develop in their roles. Managers collaborated with the local community to deliver the best possible care and were receptive to new ideas.