Last updated: 10 February 2026
"Staff feel supported in a positive team with enough people on shift, but poor safety from missing risks and medicines checks, plus weak governance, hold it back."
The service was in breach of legal regulation in relation to safe care and treatment due to shortfalls with risk management and the way people’s medicines were managed. Risks to people were not always identified, assessed and managed.
Workforce wellbeing and enablement Score:3 Staff were consistent in their positive view of the service. They told us they were well supported with regular opportunities to express their opinions or raise any concerns. 'It’s a small team and we are very supportive of each other.'
Safe and effective staffing Score:3 ... People told us there were enough staff to provide effective support. Staff said there were enough staff and they were able to spend quality time supporting people when they needed to.
Staff had not received training in RS RC RC and assessments and care plans did not include clear guidance on how to support people in a structured way. Staff had received some basic awareness training in mental health and learning disabilities but had not received training specific to the needs of people.
Governance, management and sustainability Score:1 The provider did not have clear responsibilities, roles, systems of accountability or good governance. Systems for governance and management oversight were not robust.
People told us they enjoyed activities that were offered... We observed some people taking part in activities, people were clearly engaged with artwork... quizzes and games with the staff, animals to visit the home... regular walking routine... holiday planned.
Missing risk plans for mental health changes and poor checks on high-risk medicines make safety a worry.
Risks to people were not always identified and assessed... There were no risk assessments in place for these medicines, and there was no guidance for staff in what signs or symptoms to look for.
Staff miss specialist training on mental health needs and learning disabilities, so they lack key skills.
Staff had not received training in RS RC RC... staff had not received all the training they needed to provide a specialist service... had not received training specific to the needs of people.
Management oversight failed to spot and fix issues with risks, medicines, and care plans.
Governance systems had failed to identify and rectify concerns found at this assessment... Systems for governance and management oversight were not robust.
AI Generated
Last inspected: November 2025
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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