Last updated: 9 February 2026
"A positive friendly culture where staff spoke well of managers, but serious medicines errors and gaps in training put people at risk."
The service was in breach of legal regulation in relation to the management of medicines. Medicine errors such as gaps in the medicine administration records had not been recorded.
there was a positive and friendly culture in the service. Staff spoke positively about the management team.
Sufficient staff were deployed to attend to peoples support needs, but there were gaps in staff training that meant staff would not have the knowledge to provide safe care.
there were gaps in the training matrix that meant that not all staff had the required training at this time to meet peoples’ needs.
Staff spoke positively about the management team, and leaders and how they worked together as a team, but governance and overview had not ensured safe care and audits were not robust.
there was a lack of personalised activities, and it was not clear how people were being engaged in meaningful activities which suited their individual preferences.
Medication records have unexplained gaps and errors, and risk assessments for things like epilepsy or choking are often missing, putting residents and staff at risk.
Medicine errors such as gaps in the medicine administration records had not been recorded and not all PRN (as required) medicines had protocols in place... Some risk assessments for example, for people living with epilepsy or choking were not in place.
Staff training has gaps like for blood borne viruses and managing violence, so not all team members are ready for the complex needs here.
there were gaps in staff training that meant staff would not have the knowledge, to provide safe care. For example, supporting people who lived with blood borne viruses. Staff said training was good, but they would like more training in Prevention and Management of Violence and Aggression.
No activities programme or coordinator means the job is mostly routine personal care with little variety or creativity.
there was a lack of personalised activities, and it was not clear how people were being engaged in meaningful activities which suited their individual preferences and met their expectations. People told us they were bored.
AI Generated
Last inspected: November 2025
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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