Last updated: 10 February 2026
"Staff feel supported by colleagues and managers with engaging activities and events, but serious safety risks from poor oxygen management, agency staffing delays, and missing training hold it back."
The management team and provider were not managing the risks associated with oxygen therapy in a safe way which put people at potential risk of harm.
Staff spoke well of the support they received by colleagues and managers to perform well in their jobs.
Some staff felt the morning challenges were due to a reliance on agency staff who had not worked at the home before or frequently enough.
Staff had not received training in oxygen therapy and promoting people's safety regarding this.
The management and provider had not understood or were knowledgeable about their roles in managing the risks associated with oxygen therapy at the home.
Planned trips out, parties, events involving entertainers, exercises, and games were all common place.
Big safety risks from poor oxygen storage and handling with no proper checks or risk assessments.
Portable oxygen cylinders were not being stored safely according to manufactures and best practice guidance. Systems had not been identified and developed to test and ensure the safe management of oxygen.
Morning delays waiting 15 to 20 minutes for help because of agency staff and busy times.
Some people told us they felt the mornings were busy times and they had to wait 15 to 20 minutes for support... reliance on agency staff who had not worked at the home before.
No training for staff on oxygen safety or some key health risks like choking diets.
Staff had not received training in oxygen therapy... when we asked two experienced members of staff at lunchtime, they did not have up to date knowledge of a person's specialist diet who was at risk of choking.
AI Generated
Last inspected: May 2023
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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