Last updated: 10 February 2026
"Staff training is up to date and workers feel supported, but managers' poor auditing knowledge and ineffective safety systems are major concerns."
The systems in place to keep people safe were not effective and left people at risk of potential harm. When incidents had occurred in the home, risk reviews were not always taking place.
Staff felt the home was a good place to work and felt supported and listened to.
Although we observed there were enough staff available to support people during our site visit, we could not be assured the dependency tool used was effective.
We reviewed the training matrix, and this confirmed staffs training was mostly up to date.
The registered manager and deputy manager were unable to demonstrate they understood the importance and process of auditing. For example, the registered manager told us they audited pressure monitoring charts, however what they explained to us was not an audit but a review of the information.
Not covered in recent targeted inspection report.
Managers do not understand how to audit properly, so problems with care plans and incidents go unchecked.
During our conversations with the registered manager and deputy manager they were unable to demonstrate they understood the importance and process of auditing.
Staff give conflicting advice on managing risks like falls or distress, with no updates after incidents.
Some staff were not always aware of people’s individual risks and how these were managed. This placed people at risk of significant harm. For example, a staff member told us that a person who was at risk of falls understood their risks and independently mobilised, whereas another staff member told us this person needed to be supervised.
The staffing tool misses some residents needs because care plans are not up to date, even though enough staff were on shift.
The registered manager told us there was a staffing tool in place that was used to ensure there were enough staff available for people. They told us all people’s needs were assessed through the care planning/dependency process; however, they confirmed when people had low needs this was not then added to the dependency part of the tool.
AI Generated
Last inspected: October 2024
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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