Last updated: 10 February 2026
"Staff feel supported with improving morale and complete relevant training, but staffing shortages, weak management and safety risks hold it back."
The service was in breach of the legal regulations in relation to safe care and treatment and staffing. Lessons were not learnt... incident reports recorded for 1 person showed they had experienced several falls... no immediate measures were taken. We identified gaps in the records for... missed doses of medicine... put them at potential risk of harm.
Staff felt supported, able to raise concerns and that they would be listened to. Staff told us they were proud to work for the service, and morale was beginning to improve following recent changes at management level.
There was not enough staff to meet the needs of people safely and effectively. A high number of people were assessed as being ‘very high dependency’. Several people required a high level of close supervision or monitoring, and some people required 2 staff for moving and handling support.
Some staff had not been assessed as competent in handling controlled drugs, however staff completed medicines training. Staff completed relevant training to their roles.
The service was without a manager who was registered with CQC, which is their legal duty to do so; however, the interim manager had begun the application process. There had been a high turnover of managers in the past 2 years and the provider recently appointed a manager to the service who did not have the right skills and knowledge.
People were not always supported to take part in stimulating activities or to access the community on a regular basis. Relatives commented on the lack of support for this, and it was mainly families that provided support or paid for extra staff.
Not enough staff for the high dependency needs, so you are always rushed and cant respond to people quickly.
There was not enough staff to meet the needs of people safely and effectively. A high number of people were assessed as being ‘very high dependency’. Staff could not respond to people’s risks in a timely manner due to operational pressures.
No permanent manager in post and recent ones lacked the skills to lead well.
The service was without a manager who was registered with CQC... high turnover of managers in the past 2 years and the provider recently appointed a manager... who did not have the right skills and knowledge to lead.
Medication errors like missed doses and poor incident reviews leave safety risks.
We saw 3 records where people had missed doses of medicine as there were none left to give... put them at potential risk of harm. Incident reports recorded... several falls... no immediate measures were taken to... minimise the risk of incidents being repeated.
AI Generated
Last inspected: July 2025
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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