Last updated: 10 February 2026
"A positive open culture with supportive colleagues and varied activities, but unsafe oxygen management, agency staff reliance, and training gaps are major concerns."
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; portable oxygen cylinders were not being stored safely; breach of regulation 12.
Staff spoke well of the support they received by colleagues and managers to perform well in their jobs; there was a positive open culture at the home and amongst the staff and management team.
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; people had to wait 15 to 20 minutes for support in the mornings.
Staff had not received training in oxygen therapy and promoting people's safety regarding this; we also found some shortfalls in staff practices in relation to falls, people's diets, and safeguarding.
The management and provider were not thoroughly monitoring and assessing this aspect of people's care to assure themselves and others everyone was safe in relation to the use of oxygen; managers were not always supporting staff to maintain their knowledge in their work.
There was a range of creative opportunities... Planned trips out, parties, events involving entertainers, exercises, and games were all common place; art and drama, quizzes, one-to-one chats.
Oxygen use not handled safely, with poor storage, no checks, and no staff training on risks.
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. Staff and managers had not been given training in oxygen management.
Mornings busy with long waits for help due to relying on agency staff who don't know the home well.
Some people told us they felt the mornings were busy times and they had to wait 15 to 20 minutes for support... 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.
Gaps in staff training for oxygen safety, falls prevention, special diets, and full safeguarding knowledge.
Staff had not received training in oxygen therapy... some shortfalls in staff practices in relation to falls, people's diets, and safeguarding. Staff we spoke with did not know of the outside agencies they could report their concerns to.
AI Generated
Last inspected: May 2023
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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