Last updated: 10 February 2026
"An open culture and some activities exist, but big safety failures, unsafe staffing, and ineffective management hold it back."
Medicines were not managed safely. Risks were not always identified, and staff did not always have guidance in place to reduce any risks to people.
Staff told us there was an open and transparent culture... However, no staff spoke out about the incidents we observed during our assessment.
We found on several occasions there were no staff upstairs at Alexandra House despite people being present upstairs.
care staff were not trained in this system and had no access to it.
Governance systems were ineffective and had either failed to identify issues or where issues had been identified timely action was not taken.
Staff told us they shared a minibus with other services and went out to garden centres. They also told us children from a local school visit.
Big safety failures like unsafe moving and handling of people, late pain relief, and not spotting neglect put everyone at risk.
we observed staff to support a person unsafely with their moving and handling needs... people received their pain relief late... staff did not always recognise incidents as safeguarding concerns.
Staffing is unsafe at times with no one upstairs when people need help and slow call bell responses.
there were no staff upstairs at Alexandra House despite people being present upstairs... I press my buzzer for them, but they must be busy, as it’s too late by the time they come.
Managers miss problems in their checks and do not fix repeated issues like poor wound care quickly.
limited action had been taken to improve pressure area care following a serious incident... same issues were reported on and found repeatedly, with little action taken.
AI Generated
Last inspected: July 2023
Management Quality
Well-led: Good
Direct feedback from current and former employees

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