Last updated: 10 February 2026
"Staff get good training, supervisions and work in an open culture with varied activities, but safety issues like choking risks went unmanaged and unnoticed by managers."
Choking risks had not been managed safely. Nurses had introduced and prescribed the use of thickener without direction or advice from the Speech & Language Therapy Team (SALT) this placed people at risk of harm.
The registered manager promoted an open culture. Staff received supervisions and had the opportunity to speak out.
Enough staff were deployed to meet people's needs. Staffing levels were calculated using a dependency tool which looked at the needs of each person.
Per 2018 comprehensive inspection: Staff felt well supported and received regular supervision sessions and annual appraisals. The majority of staff were up to date with training.
The issues identified during the inspection had not been recognised or identified by the provider or registered manager. This meant the provider's quality assurances were ineffective.
Per 2018 comprehensive inspection: The provider had employed a part-time activity co-ordinator who organised a variety of activities including visits from external entertainers and also spent time with people on a one to one basis.
Manager and provider did not spot safety issues like choking risks from thickener and poor agency staff checks.
The issues identified during the inspection had not been recognised or identified by the provider or registered manager.
Choking risks handled poorly as nurses used thickener without speech therapist advice.
Choking risks had not been managed safely. Nurses had introduced and prescribed the use of thickener without direction or advice from the Speech & Language Therapy Team (SALT)
Agency staff allowed access without checks on identity, training, or recruitment records on two occasions.
Agency staff were allowed access to vulnerable people on 2 occasions when the home did not have information about their safe recruitment, training and identity.
AI Generated
Last inspected: March 2023
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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