Last updated: 9 February 2026
"Sufficient staffing and supportive culture for staff, but missing governance audits and outdated risk assessments hold it back."
The reviewing and recording of people’s risks in their care plans had not routinely taken place, placing people at potential risk of harm... The medicines system being used was safe, but unsustainable.
Staff explained they felt supported and motivated by the leadership at the service. One member of staff told us, “We always do the best we can, the manager always makes us do that and helps us to be the best we can be.”
Staff rotas showed there were sufficient numbers of suitably qualified and trained staff consistently deployed to fully meet people’s needs.
Staff had received relevant training in looking after people. Staff completed an induction when they started working at the service and ‘shadowed’ experienced members of staff until they were assessed as competent to work unsupervised.
We found one breach of the legal regulations in relation to systems of quality monitoring and governance. Governance systems and audits were not in place, and had not identified or addressed areas for improvement.
No checks or audits in place, so problems like out of date risk assessments and care plans were not spotted or fixed.
Governance systems and audits were not in place, and had not identified or addressed areas for improvement.
Risk assessments in care plans not kept up to date, and meds handled through a temporary time-consuming system that depends on the manager.
the risk assessments in people’s care plans had not been routinely reviewed... medicines system being used was safe, but unsustainable. It is understood this is an interim system to cut down on previously identified medicines errors.
Only standard induction and basic training, no specialist courses or funded qualifications for career growth.
Staff completed an induction when they started working at the service and ‘shadowed’ experienced members of staff until they were assessed as competent.
AI Generated
Last inspected: October 2024
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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