Last updated: 9 February 2026
"Safe staffing and an open inclusive culture, but gaps in care records risking harm, poor training and weak oversight are major concerns."
People were at potential risk of harm because records didn't always evidence care being provided in line with individual care plans, risk assessments had not always been completed.
The culture of the service was open and inclusive, and staff worked with other professionals to ensure people achieved good outcomes.
Staff were recruited safely, and there were enough staff to meet people's needs.
staff had not completed training specific to people's needs.
Governance systems had failed to identify the concerns identified at this inspection.
Care records show big gaps, like up to 15 hours between repositioning bed-bound people, risking pressure sores.
One person was cared for in bed and required assistance to re-position every four hours. Their records showed regular gaps of much longer periods of time between re-positions, at times up to 15 hours.
Staff lack key training for residents' needs, like spotting swallowing problems that could lead to choking.
Staff had not completed dysphagia training and did not have up to date knowledge about the international dysphagia standard terminology.
Leaders missed major risks and problems that inspectors found, showing weak oversight.
Governance systems had failed to identify the concerns identified at this inspection.
AI Generated
Last inspected: May 2023
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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