Last updated: 10 February 2026
"Staff feel passionately supported, but unsafe medicines management and recruitment without references hold it back."
Medicines management was not always safe. Medicine stock did not match the numbers indicated on the medicine administration records. Staff had not completed medicine competencies.
Staff we spoke with felt passionately about supporting and empowering the people at the service. Staff told us, "No matter where they are, they are always ready to come and really fast. They are really supportive – they are always there when I need any support or advice."
People were supported by staff who had not always been recruited safely. We found gaps in employment history had not been explored. No references had been obtained to check the character of the staff.
Staff had completed medicine training but had not received any competency checks to ensure they were safe to administer medicines. Staff did not always have the training, skills and experience needed to de-escalate people's distress.
The provider had not completed any checks or audits on the service to seek to improve it or identify any areas for improvement. There was a lack of oversight in relation to medicines management, recruitment, training and risk management.
People were supported to maintain their mental wellbeing by accessing groups. People enjoyed walking and were supported to maintain their physical and mental health through regular exercise.
Medication stock does not match records and staff have not been checked as competent to give meds safely.
Medicine stock did not match the numbers indicated on the medicine administration records. Staff had not completed medicine competencies.
Staff hired without full checks like references or explaining gaps in work history.
We found gaps in employment history had not been explored. No references had been obtained to check the character of the staff.
No training on calming people in distress or follow-up talks after tough incidents.
Staff did not always have the training, skills and experience needed to de-escalate people's distress. There was not always evidence that following incidents staff were offered the opportunity for a de-brief or supervision.
AI Generated
Last inspected: March 2023
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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