Last updated: 10 February 2026
"Staff feel supported in a positive culture, but staffing shortages, poor safety management and training gaps put people at risk."
Risk assessments not always clear, comprehensive and up to date; fire safety risks not well managed, no fire drills, intermittent alarm tests; no analysis of incidents
Staff gave us positive views about how well supported they were and about the culture within the service, changed for the better since new management
There were not always enough staff deployed on shift to meet people’s needs and provide safe care; observed rota with only 1 night staff when 2 needed, putting staff and people at risk, staffing breach
Some staff had not received all the training they needed to support people safely; only 7 staff trained in emergency epilepsy medicines despite people with epilepsy living there
new manager who was in the process of registering with the Care Quality Commission, supported by registered manager from another service; quality monitoring and audit processes were not always robust, breach of good governance
Some people supported to gym 2-3 times a week and town; relatives felt loved ones would benefit from more stimulation and community activities; staffing limited outings
Not enough staff on shifts like nights when two are needed, so you risk unsafe moving and handling and miss community outings with people.
We observed the staffing rota for the day of our site visit only had 1 member of night staff allocated and... only allocating 1 staff member on shift was putting the staff member and people at risk
Risks like falls, skin sores, seizures and fire not fully covered in assessments or managed well, with no fire drills done.
Risk assessments were not always clear, comprehensive and up to date... Fire safety risks had not been well managed, fire drills had not taken place
Training gaps mean not all staff can handle key needs like epilepsy emergency meds or fire procedures safely.
training records showed only 7 staff in total had done training relating to emergency medicines prescribed to treat epileptic seizures... staff told us they had not had fire drills
AI Generated
Last inspected: February 2025
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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