Last updated: 10 February 2026
"Adequate staffing with the right skills and good training support staff well, but unsafe medicines management and weak governance put people at risk."
Medicines were not always managed safely; people were put at a significant risk of harm. The provider was in breach of legal regulations, due to the concerns found regarding people’s medicines safety.
Staff told us they were encouraged to give feedback and felt confident feedback given was taken as positive and acted upon. We received overall positive feedback from staff however some feedback indicated staff were unhappy.
People were supported by enough staff, with the right skills and knowledge to safely support people. Appropriate staffing levels were in place, including an appropriate skills mix, to ensure people received good quality care that meets their needs.
Staff received training appropriate and relevant to their role and told us they were given the support they needed to deliver safe care. This included supervision, appraisals and support to develop their skills.
Governance systems and processes were not robust, which effected the services ability to correctly assess, monitor, and improve the quality and safety of care in which people received. The provider was in breach of legal regulations, due to the lack of overarching governance systems.
Medication is not always handled safely, with problems like incomplete records for patches and poor storage temperatures putting people at risk.
Records relating to transdermal patch application and rotation were incomplete... Further improvements were required in the safe storage, disposal, and temperature monitoring of medicines. The medicines room was not consistently maintained within the recommended temperature range
No strong oversight systems in place, as audits missed key issues like medication risks.
While audits were being completed, they were not sufficiently robust in identifying key areas requiring improvement. The audits failed to identify the issues we found during the inspection. Medicines audits had not identified several key risks
Staffing levels are enough but there are lots of different faces due to changes, suggesting turnover or agency use.
some people noted frequent changes in staff, with one saying, “I think there are a lot of staff, but we see lots of different faces.”
AI Generated
Last inspected: August 2025
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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