Last updated: 10 February 2026
"A proactive positive culture and sufficient skilled staff, but weak governance, safety breaches around mental capacity and poor quality monitoring hold it back."
The service was in breach of legal regulation in relation to people’s safe care and treatment and safeguarding people from abuse. Mental capacity assessments and best interest decisions had not consistently been completed.
The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events.
There were sufficient staff available, with the right skills and experience to keep people safe and provide high quality care. However, we found gaps in recruitment records.
Staff told us they completed a range of training that gave them the skills and knowledge required to meet people’s needs and keep them safe. However, one staff member said, “We support some very complex people, and it would be helpful to have more training on how to deal with people who are challenging.”
The service was in breach of legal regulation in relation to good governance. Quality monitoring systems were in place but not always effective.
There were planned group activities for people to take part in if they wished to do so. Staff had a good understanding of people's interests, likes and dislikes.
Locked bedroom doors for some residents without proper mental capacity paperwork and best interest checks, so restrictions weren't always justified legally.
mental capacity assessments and best interest decisions had not consistently been completed. In cases where best interest decisions were recorded, it was unclear whether the least restrictive options had been actively considered.
Managers' quality checks missed risks like poor cleaning, unsafe furniture, and window issues.
Some areas for improvement we identified during the site visit had not been detected by the provider's quality monitoring systems. For example, people were at risk of harm from unmanaged risks in the premises.
Gaps in staff recruitment records mean background checks on new hires weren't always complete.
we found gaps in recruitment records. The registered manager was responsive to the concerns raised and immediate action was taken for the records identified and a review of other records was to be completed.
AI Generated
Last inspected: November 2025
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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