Last updated: 9 February 2026
"Engaging activities with therapists and a supportive culture for staff, but staffing shortages and medicines safety issues need improvement."
We found some people had not received their medicine due to lack of stock... The provider had failed to ensure the safe management of medicines. This was a breach of regulation 12... Risk assessments were completed for people who needed support relating to malnutrition and mobility. However, for people with more complex risks these were not in place.
Staff mostly told us they felt supported by the registered manager and the nursing team and confirmed they had supervisions on a regular basis.
Although there were enough staff to meet peoples' basic needs, people and staff told us there were not enough staff to ensure staff were able to spend quality time with people. 'They have been so short of staff the last few weeks, especially today… Three of the carers [on this unit] today are from another home.'
We received mixed views about the training staff received. One person told us, 'They (staff) are not up to scratch some of them don't even know my condition.'
Governance systems in place had failed to identify a number of issues we picked up during our inspection in relation to medicine management, risk management and person-centred care planning. The provider did not effectively operate systems to ensure compliance with the regulations. This was a breach of regulation 17.
A music therapist worked three days each week running groups or individual sessions. There was also a physiotherapist who encouraged people to be active and have access to team and sports games.
Not enough staff for quality care time, with agency workers covering and long waits for help like pain meds or the toilet.
'Sometimes you can't see any staff around anywhere... They have been so short of staff the last few weeks, especially today… Three of the carers [on this unit] today are from another home.'
Medicines run out so people miss doses, and no proper plans for risks like seizures.
We found some people had not received their medicine due to lack of stock. For example, medicines to treat urinary spasms was not available on 10 July 2019... one-person experienced frequent seizures and did not have a risk assessment in place.
Weak oversight with repeated inspection problems and governance failures not spotting medicine or risk issues.
This service has been rated as requires improvement for four consecutive inspections... Governance systems in place had failed to identify a number of issues we picked up during our inspection in relation to medicine management, risk management.
AI Generated
Last inspected: November 2019
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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