CQC Location ID:1-135073187
Date of assessment: 05 November 2025 to 12 November 2025. We carried out a comprehensive inspection of the service following information of concern that staff were not consistently recognising or escalating people’s health deterioration. The inspection assessed all key areas of the service, including people’s care and treatment, risk management, medicines, staffing, and governance. We looked at how staff assessed, planned, and reviewed people’s needs, and how the provider monitored and maintained the quality and safety of the service. We identified concerns that could place people at risk of avoidable harm. The provider was in breach of regulations relating to consent to care, safe care and treatment, and good governance. Staff did not consistently assess, plan, or review people’s needs and risks. While staff completed recognised assessment tools, these were not always used to guide daily care or prompt timely action. Some people did not have key care plans, including plans for advanced decisions and end-of-life care. Risk assessments, best-interest decisions, and guidance for escalation were sometimes missing or unclear, so staff did not always have the information they needed to provide safe care. The provider did not consistently identify or manage environmental or medicines-related risks. Routine checks and audits did not highlight gaps in care planning, medicines management, or safety, and some issues were only addressed after the inspection. Staff reported feeling under pressure and unsupported, which affected their ability to deliver consistent care. However, people and relatives said staff were kind, caring, and committed. We have asked the provider for an action plan in response to the concerns found at this assessment relating to consent, safe care and treatment and governance.
People and relatives described staff as kind, professional, and attentive. People we spoke with told us that staff supported them effectively with personal care, mobility, and day-to-day health needs. Relatives valued being able to visit without restrictions and told us their loved ones were treated with dignity and respect. Most people told us staff responded promptly to call bells and provided care in a timely manner. A small number of people and relatives said that, at times, staff appeared busy or stretched, which occasionally resulted in longer waits for assistance. These instances were not reported as consistent concerns. One person told us, “They try and come quickly but there are a lot of people here so sometimes I have to wait”. Another person said, “I think they’re a bit pushed on staff. I wanted a shower this morning, but it was late when they got me up so there wasn’t time, but I’ll ask them for one this afternoon if staff are available”. People’s experiences of activities varied. Some participated in small group sessions or occasional film screenings, while others described limited opportunities or unclear communication about activities. One person told us, “There is a chart in the kitchen area of activities, but they don’t necessarily keep to it”. Another person told us, “I haven’t seen any activities”. They do lay things on in the big rooms at the end, but I never know when and what’s going on”. This meant some people spent extended periods with little planned engagement or stimulation. Feedback about meals was also mixed. Some people were satisfied with the food provided, while others described limited choice, repetitive menus, or meals that did not always meet individual preferences. A small number of relatives reported providing additional food from home to ensure their loved ones received meals they enjoyed or could manage safely. While people and relatives expressed general satisfaction with their care and the kindness of staff, our assessment found that some aspects of care did not consistently meet the expected standards.