Last updated: 9 February 2026
"Staff felt able to raise concerns comfortably, but infection control failures, heavy agency staffing reliance, and unmanaged safety risks held it back."
Not all risks to people's safety had been identified and/or acted on in a timely manner. The 29 July 2022 team meeting minutes noted the ramp used by people to access the garden, 'Is still broken so please keep in mind when the people we support go out it is dangerous.'
Staff felt able to raise concerns with managers without fear of what might happen as a result. A staff member told us they, 'Definitely,' felt comfortable to raise any issues during staff meetings.
During the second day of our inspection, there was only one permanent staff member on duty, and two agency staff, who had not worked at the service before. There was not sufficient cover to provide the one to one support and flexibility of people if they wanted to go out.
Improvements were needed to ensure all staff completed their mandatory and refresher training to keep their skills and knowledge up to date. This included food safety, data protection, fire safety and safe use of restrictive interventions.
Systems were not robust enough to evidence effective oversight of the service. This demonstrated a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014.
People were supported to participate in their chosen social and leisure interests on a regular basis. One person told us how they enjoyed going to the beach... playing pool and visiting the local farm.
AI Generated
Last inspected: December 2022
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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