Last updated: 10 February 2026
"Residents enjoy communal activities, but safeguarding failures, unsafe staffing with long shifts, and training gaps hold it back."
People were not routinely protected from abuse, the service failed to always recognise or act on allegations of abuse. The risks to people because of their medical conditions were not always assessed in a timely manner. Medicines were not always managed safely.
nursing and care staff told us they did not always have confidence in the management team to follow up on safeguarding concerns. Some staff felt the registered manager lacked management skills to deal with conflict and issues as they arose.
feedback from staff showed staff felt the staffing levels were not sufficient as were based on the number of people living in the service as opposed to their needs. Staff told us the rota was poorly managed and this resulted in some staff having to work long stretches of 12-hour shifts in a row. Safe recruitment practices were not promoted.
In training records viewed we saw there was gaps in training such as emergency first aid and fire warden training. The training records for nurses showed training was not provided for the nursing tasks they were undertaking such as catheter care, wound management, Percutaneous Endoscopic Gastrostomy (PEG) feeding.
The registered manager failed to have oversight of staff and responsibilities delegated to them. This impacted on people’s safety. The provider’s systems for auditing the success of the service were not effective and did not identify the concerns we found.
People appeared to enjoy communal activities which occurred throughout the day. We saw people smiling and laughing with staff.
Staff feel there aren't enough of them because levels are based on resident numbers not care needs, rotas are badly managed leading to long 12-hour shifts in a row, and recruitment checks like references are often missing or wrong.
feedback from staff showed staff felt the staffing levels were not sufficient as were based on the number of people living in the service as opposed to their needs. Staff told us the rota was poorly managed and this resulted in some staff having to work long stretches of 12-hour shifts in a row. Safe recruitment practices were not promoted, and the service was not working in line with the providers reference policy.
There are big gaps in staff training like first aid, fire safety, and nurses miss training for wound care, catheter care, and feeding tubes so they might not have the right skills.
In training records viewed we saw there was gaps in training such as emergency first aid and fire warden training. The training records for nurses showed training was not provided for the nursing tasks they were undertaking such as catheter care, wound management, Percutaneous Endoscopic Gastrostomy (PEG) feeding.
Safeguarding fails because abuse concerns aren't always spotted or reported, risk assessments are late or weak, and medicines run out so residents miss important doses.
The service failed to have systems and processes in place to ensure people were protected from abuse. Staff failed to identify events which had the potential to cause harm to people and report them to the local safeguarding authority. Medicines were not always managed safely. The ordering process for prescribed medicines was not safe and effective. As a result, people went without essential prescribed medicines.
AI Generated
Last inspected: September 2024
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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