Last updated: 10 February 2026
"Positive staff culture and good training, but blank incident reviews without monitoring and weak recruitment processes hold it back."
Incident forms contained a review section to be completed by management for monitoring themes and trends... These sections were blank and the registered manager had no other recorded process.
Feedback from staff and external health care professionals was also positive.
Systems and procedures for recruiting new staff were not robust... could not produce any evidence of this in relation to 2 staff whose records we reviewed.
Staff received training and completion of this was monitored. Competency checks did not always take place or were not recorded.
The registered manager promoted a learning culture... However, this would be better supported through more robust systems and processes of management.
Accident reports and risk assessments often have blank sections with no follow-up actions or trend monitoring.
Incident forms contained a review section to be completed by management for monitoring themes and trends, including questions relating to whether the accident/incident was preventable; whether staff followed correct procedures; and had there been any further investigation, actions and outcomes. These sections were blank
New staff start work without full criminal record checks and no proof they were supervised properly.
staff being allowed to work without a full Disclosure and Barring Service (DBS) being completed, a lack of appropriate risk assessment... The registered manager told us staff were supervised whilst they were waiting for their full DBS to come through but could not produce any evidence of this
Staff finish training courses but bosses do not check or record if they can actually do the job competently.
Staff competency checks did not always take place or were not recorded... there were no records of these [medicines competency spot checks]
AI Generated
Last inspected: July 2025
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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