Last updated: 10 February 2026
"Consistent staffing met residents' needs, but poor management oversight missed safeguarding alerts and safety risks caused a serious injury."
The inspection was prompted by the notification of an incident following which a person using the service sustained a serious injury. [...] the information shared with the CQC about the incident indicated potential concerns regarding the management of the risk of falls from height.
There was a culture within the service whereby staff did not feel confident to challenge any inequalities they observed or seek to find solutions to the barriers people faced.
People were supported by a consistent staff team. Staffing levels were determined by the needs of the people who used the service.
At the last inspection the registered manager did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. At times there was a lack of oversight, which had led to incidents that should have triggered safeguarding alerts, being missed.
During this inspection, we observed that activity boxes had been introduced and were available for people to access independently.
Managers missed some alerts about possible harm or abuse due to poor oversight, even though things are improving.
at times there was a lack of oversight, which had led to incidents that should have triggered safeguarding alerts, being missed.
Safety risks like falls from height havent been fully managed, leading to a serious injury that prompted this inspection.
The inspection was prompted by the notification of an incident following which a person using the service sustained a serious injury. [...] potential concerns regarding the management of the risk of falls from height.
No activities coordinator or varied programme, just basic activity boxes, so the job is mostly routine personal care.
activity boxes had been introduced and were available for people to access independently.
AI Generated
Last inspected: November 2025
Management Quality
Well-led: Inadequate
Direct feedback from current and former employees

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