Last updated: 10 February 2026
"Good training and supportive culture, but safety risks from incorrect medicines and thickeners, plus stretched staffing hold it back."
Breach of safe care and treatment: medicines not always given before/after food correctly; staff not always using correct formula for fluid thickener risking choking.
Staff told us they worked well together and in the best interests of the people; felt more supported since new registered manager after previous concerns.
Staff told us there were generally enough staff on duty but staffing levels didn’t change if people’s dependency increased; no additional cover when staff supported appointments.
Staff received appropriate induction, training, and supervision; confirmed they were given appropriate training relating to their job role and could request specific qualifications.
Staff generally felt there had been some improvements to the management and governance since the appointment of the current registered manager, but previous staff survey raised concerns about lack of confidence to raise concerns and personal development.
People attended the homes activities and enjoyed the planned events; told us 'I sometimes join in with activities'.
Staff make mistakes mixing thickeners for drinks and giving meds at wrong times, putting people at risk of choking or poor treatment.
Staff were not always using the correct formula to mix fluid thickener in drinks to aid swallowing... Some medicines to be administered before and after food, were not always given correctly. This was a breach of safe care and treatment legal regulations.
Staff get too busy and stretched, with lounges left unsupervised and no extra help when needs go up or for breaks.
We observed communal lounges were often left unsupervised for long periods of time... staffing levels didn’t change if people’s dependency increased... no additional cover which meant sometimes, staff didn’t always get their breaks.
Records and risks not always updated quickly or spotted by checks, so care plans can be wrong after hospital stays.
Risks to people were assessed but records were not always updated promptly when people’s needs changed... care records were not updated in a timely manner... Governance processes did not always highlight where there were gaps in care records.
AI Generated
Last inspected: October 2024
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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