Last updated: 9 February 2026
"Managers are visible and staff feel supported, but unreported bruising, poor supervisions and inadequate agency training are major concerns."
We saw failure to report some bruising on a person to a team lead or manager had resulted in a failure to investigate the concern. The concern had also not been shared with the local safeguarding team for further investigation.
The management team were visible in the service. Staff told us they felt they could approach the management team if they had concerns.
People were supported by adequate numbers of staff, although the service depended on regular agency staff use. Staff told us efforts were always made to cover all the shifts needed. However, training and support for agency staff was not robust.
Staff did not always receive regular supervision, which meant some opportunities to identify gaps in their knowledge could be missed. Agency staff were not given the same training in restrictive practices as the established staff team.
Systems had not always enabled the management team to assess, monitor and mitigate risks to the health, safety and welfare of people using the service. This was a breach of regulation 17(1)
Unexplained bruising on residents was not reported to managers or safeguarding teams, so causes and risks were not checked.
We saw failure to report some bruising on a person to a team lead or manager had resulted in a failure to investigate the concern. The concern had also not been shared with the local safeguarding team for further investigation.
Management checks are weak and miss risks, letting staff go a year or more without supervisions.
A system to ensure staff received adequate supervision had failed to enable the management team to identify and act on the fact that some staff had not received formal supervision for over a year.
They use agency staff regularly but those workers skip key training like safe restraint that permanent staff get.
However, agency staff supporting the same people were not provided with the same accredited training. Agency staff also received little or no formal supervision.
AI Generated
Last inspected: June 2023
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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