Last updated: 9 February 2026
"Staff work well together and are committed to care, but low staffing with sleeping night staff and poor safeguarding plus medicines management hold it back."
Safeguarding processes were not robust—one safeguarding incident and a physical assault were not notified to CQC as required by law. Medicines were not managed safely, for example: PRN protocols were missing, and handwritten MAR charts were not countersigned.
Staff told us they worked well together and were committed to people’s care, but governance of staffing was weak. Staff reported low staffing levels and rota issues affecting morale and communication with the management team was poor.
Staffing levels did not always meet basic care needs and did not allow people to go out as often as planned. Throughout the night there were 2 staff on shift, between 11pm and 7am, these members of staff were asleep.
Training was mainly online, with gaps in key areas such as autism awareness and end-of-life care. Staff had some Infection Prevention Control training, but not all were up to date.
The registered manager had not identified many of the shortfalls we found. There was no systematic approach to staffing levels or skill mix.
People enjoyed activities such as games nights and occasional outings. However, both relatives and staff told us opportunities to go out were limited because of staffing levels.
Not enough staff on duty to meet basic needs safely, with sleeping night staff missing calls for help.
Staffing levels did not always meet basic care needs... Throughout the night there were 2 staff on shift, between 11pm and 7am, these members of staff were asleep. However, throughout our assessment, there was 1 person who could not use their call bell or gain staff attention.
Safeguarding incidents like assaults not reported properly and medication records incomplete or unsigned.
one safeguarding incident and a physical assault were not notified to CQC as required by law. Medicine Administration Records (MAR) charts had missing signatures, handwritten entries were not countersigned, and PRN protocols were absent.
Manager overlooking major risks and safety issues with audits not done or followed up.
The registered manager had not identified many of the shortfalls we found. Audits for medicines, infection control, and daily notes were either not completed or lacked follow-up.
AI Generated
Last inspected: September 2017
Management Quality
Well-led: Good
Direct feedback from current and former employees

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