Last updated: 9 February 2026
"Staff receive good training in a positive culture, but safety risks, poor cleanliness and unclear staffing were not managed well."
The provider did not always assess risks to ensure people were safe... skin cream was not stored safely... posed a risk of fire... no fire extinguishers... Radiators were not covered... The provider had not always identified and managed risks to people's safety and wellbeing. This was a breach of regulation 12... The provider had failed to ensure infection control risks were managed and mitigated. This is a breach of Regulation 12.
Staff felt well supported by the management team and they could approach them for support. Staff said they could have their say at meetings... Overall, there was a positive culture in the service... One person told us, 'It's like a family.' A staff member told us... 'We get a lot of support from the other staff as well.'
When we arrived, there were no staff present at 1 Hill Close... Rotas and dependency tools showed that no night staff were provided at 1 Hill Close. However, inspectors were informed 2 night staff were shared... This was not properly reflected in the rotas and dependency tools we saw. We recommend the provider review their staff rotas and dependency tools... to ensure there are sufficient staff deployed to provide safe support to people on a 24-hour basis.
Staff received training to help them to deal with situations where people displayed behaviour that communicated distress... Staff told us they received training on what to do to make sure people were protected from harm or abuse. Records we saw confirmed this. Staff who administered people's medicines had completed appropriate training. Per 2017 comprehensive inspection: Staff undertook a thorough induction... programme of mandatory refresher training... regular supervision meetings and an annual appraisal.
The registered manager carried out a range of checks and audits to monitor the safety and quality of the service. However, there were areas of concern that had not been identified during these audits. This included shortfalls in the assessment and management of risk, shortfalls in cleanliness and a lack of clarity in relation to staff deployment. The provider had failed to ensure effective and robust governance systems were in place... breach of regulation 17 (governance)
Throughout the day, people were doing various activities they had chosen... We saw people went out and about at different times throughout the day... visit the barber... enabled to attend football matches... More than 1 person had really enjoyed following the England football team's progress in the Women's World Cup.
Safety risks like medicines stored next to a hot oven and dirty areas with dried poo on surfaces and no hand drying were not managed well.
dried excrement on various surfaces upstairs. The kitchen cupboards, fridge, freezer and oven were dirty... There were no facilities in the toilets or the kitchen for staff to dry their hands... one person's skin cream was not stored safely... The cabinet was positioned, pushed up against the oven housing. The veneer on both the cabinet and the oven housing were visibly scorched. This posed a risk of fire.
Staff deployment is unclear because rotas do not show shared night staff properly and no one was on site when inspectors arrived.
When we arrived, there were no staff present at 1 Hill Close... Rotas and dependency tools showed that no night staff were provided at 1 Hill Close. However... 2 night staff were shared between 1 Hill Close, 2 Hill Close and Hillcrest. This was not properly reflected in the rotas and dependency tools we saw.
Manager's checks missed problems like poor cleanliness and safety risks so oversight is not reliable.
there were areas of concern that had not been identified during these audits. This included shortfalls in the assessment and management of risk, shortfalls in cleanliness and a lack of clarity in relation to staff deployment... The provider had failed to ensure effective and robust governance systems were in place... breach of regulation 17 (governance)
AI Generated
Last inspected: December 2023
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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