Last updated: 9 February 2026
"Staff feel supported with good training, but unsafe beds caused serious injury and weak governance missed key risks."
People were not protected from avoidable harm. For example, out of the total 6 bedrooms, there were 2 bedrooms which had a gap between the mattress and headboard. As a result, one person suffered injuries and was taken to the hospital for treatment, there was no risk assessment.
Staff told us they felt supported and could approach their line manager at any time for support. Staff were positive about how the service was run and the support they received from the management team.
There were enough staff to support people at the service and to attend appointments when required. Staff told us they felt there were enough of them to meet people's needs safely and appropriately.
Training records confirmed that staff had completed training that was relevant to people's needs. This training included safeguarding adults, medicines administration, health and safety, fire safety, behaviours that communicate a need, learning disability, and equality and diversity.
The systems in place to understand and address the quality and safety issues within the service were not operating effectively. This was a breach of regulation 17 (Good Governance).
People were supported to follow their interests and take part in activities. These included listening to music, accessing day care centre and local community. One relative said, 'My [name] is able to attend the weekly trips out'.
Beds had gaps that hurt someone bad enough to go to hospital, and similar risks weren't fixed in other rooms.
out of the total 6 bedrooms, there were 2 bedrooms which had a gap between the mattress and headboard. As a result, one person suffered injuries and was taken to the hospital for treatment, there was no risk assessment, and no action was taken to mitigate this risk, prior to the incident.
Quality checks missed safety problems like unsafe beds and missing legal papers for restricting freedom.
The quality assurance system and processes had failed to identify and correct issues we found at the inspection... The systems in place to understand and address the quality and safety issues within the service were not operating effectively.
Only basic trips out, music, and day centre, no activities coordinator or special programmes to make the job more interesting.
People were supported to follow their interests and take part in activities. These included listening to music, accessing day care centre and local community.
AI Generated
Last inspected: November 2023
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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