Last updated: 10 February 2026
"A positive culture with caring staff and an improving new manager, but serious safety gaps in safeguarding and medicines plus unreliable staffing hold it back."
Safeguarding concerns were not always managed robustly... the provider had not always followed processes to ensure this was maintained in line with the Mental Capacity Act (2005). This is a breach of Regulation 13... There was a lack of clarity over how staffing levels were managed and there were concerns around medicines management... Full counts of medicines were not undertaken robustly.
All the staff we spoke with told us they would be happy for one of their relatives to live at the service should the need arise. One member of staff said, ‘Yes I would (be happy for a member of my family to live here), the staff genuinely care and want the best for the clients.’ Staff told us they could speak with the new manager and they seemed fair and approachable with all staff.
The feedback from staff around staffing levels were mixed. One member of staff felt they didn’t know whether there was meant to be 2 or 3 members of staff on duty each day as the levels varied... Our review of the staff roster showed it was not always being used to document clearly what staff were meant to be on duty... there were two shifts per day which simply stated, ‘cover needed’.
Staff told us they had received training in safeguarding adults and knew where the safeguarding policy was... Staff who administered medicines told us they had received training for their role and were supported by their manager to undertake competencies when administering medicines.
There had been a new manager appointed recently. Staff felt the appointment of the new manager was beneficial to the service. They felt it was early days but could see improvements since the manager had been in post. Staff had been supported recently with supervisions but we saw there had been a long period of time when they had not received regular support and supervisions.
One staff member said, ‘We give (people) choice... For example, we have a person who likes gardening. I help them with their gardening rota.’... On the first day we arrived there were 2 staff on duty and a member of staff from head office came to support a person on a community activity.
Not enough reliable staff some days because rotas show gaps marked cover needed with no record if they got filled, and levels vary between 2 or 3 even though some people need one to one.
Our review of the staff roster showed... two shifts per day which simply stated, ‘cover needed’. The manager was unable to show if these shifts had been covered by staff... 2 people required 1 to 1 support each day.
Serious safety gaps like not handling safeguarding concerns properly, missing mental capacity paperwork, and poor checks on medication so you do not always know if any is missing.
Safeguarding concerns were not always managed robustly... Where people had been deprived of their liberty the provider had not always followed processes... breach of Regulation 13... Full counts of medicines were not undertaken robustly, this meant if medicines went missing, staff... would not always know when they went missing.
New manager is trying but there were long gaps without supervisions or staff meetings, and overall oversight of care has been weak.
Staff had been supported recently with supervisions but we saw there had been a long period of time when they had not received regular support and supervisions... There was no evidence of staff meetings (although a member of staff told us there had been one recently).
AI Generated
Last inspected: September 2024
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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