Last updated: 10 February 2026
"Enough staff and an inclusive culture, but poor safeguarding, unmanaged risks, and weak leadership oversight hold it back."
Safeguarding concerns had not always been appropriately identified and referred to the local authority or reported to CQC. The provider had not taken prompt and effective action to manage incidents of neglect.
Staff and relatives commented on the inclusive culture at the service. One relative told us, '[The registered manager] is very busy but even when working [their] door is open - a true open door policy'.
There were enough staff to meet people's needs and there was always a visible staff presence in all the communal areas of the service.
The majority of staff had received safeguarding training, however four established staff members did not have a record of this training on the training matrix we reviewed.
Poor management of safeguarding and risk led us to question the quality of leadership and provider oversight.
Per 2017 comprehensive inspection: one activity coordinator who worked 25 hours per week... People were offered a wide range of both group and individual activities that were meaningful to them.
Safeguarding issues not always reported to authorities, and risks like choking or falls not managed well by all staff.
Safeguarding concerns had not always been appropriately identified and referred to the local authority or reported to CQC. Risks were not always well managed and care plans did not make clear all risks.
Managers not strong on overseeing risks and handling safeguarding properly.
This led us to question the quality of the leadership of the service and provider oversight. Effective systems were not in place to assess, monitor and mitigate risks.
Some experienced staff missing training records, and training not detailed enough for complex roles.
four established staff members did not have a record of this training on the training matrix we reviewed. Staff received training for their roles but this needed to be more in depth in some cases.
AI Generated
Last inspected: April 2023
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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