Last updated: 10 February 2026
"Unstable management, staffing shortages, and safety breaches create a distrustful culture with minimal activities."
The provider was in breach of legal regulation in relation to safeguarding, infection prevention and control, people’s safe care and treatment, the way people’s medicines were managed
The culture in the service was not based on trust and the local management team had limited confidence that accurate information was recorded
The provider did not always make sure there were enough qualified, skilled and experienced staff. ... One person told us, “There are definitely not enough staff. ... waited up to 1 hour.”
there had not been a stable management team in the service for 6 months. There was limited trust between the registered manager and the clinical team
People were sat in communal lounges with minimal engagement and interaction from members of staff
Not enough carers on shift and heavy use of agency staff, so residents wait up to an hour for toilet help and care feels rushed.
“There are definitely not enough staff. If you ask for help to go to the toilet, it varies how long you have to wait. It can be 10 or 15 minutes or I have waited up to 1 hour.”
Medication errors like out of date creams and poor recording of pain patches make giving meds risky.
We found out of date prescribed medicated cream in a person’s wardrobe... Pain patch rotation charts were not updated accurately and associated body maps were not completed.
Unstable management team for six months with no trust between manager and clinical staff, and no access to key policies.
there had not been a stable management team in the service for 6 months. There was limited trust between the registered manager and the clinical team... staff team did not have access to a current safeguarding adults policy.
AI Generated
Last inspected: April 2025
Management Quality
Well-led: Good
Direct feedback from current and former employees

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