Last updated: 9 February 2026
"A strong inclusive culture where people and staff are listened to and enough staff on shifts, but prolonged lack of a permanent manager and unsafe medicines handling held it back."
Medicines were not always managed safely. This was a breach of regulation 12(1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
There was a strong inclusive culture in the service. People, relatives, and staff were listened to and involved in the running of the service.
We reviewed the staff rosters for the four weeks prior to the inspection and noted there were enough staff on the shifts to meet people's needs.
The previous registered manager left the service in July 2021, there had been no manager in post till the appointment of the current registered manager in January 2022. Robust management cover had not been put in place and this had impacted on the service.
Activities and meals were planned inclusively with people. This included having representatives from people living in the service on the activity planning team.
No permanent manager for six months, which left staff without guidance and let quality slip,
The previous registered manager left the service in July 2021, there had been no manager in post till the appointment of the current registered manager in January 2022. Robust management cover had not been put in place and this had impacted on the service.
Medication errors like delays getting medicines and poor records, plus missing risk checks for diabetes and skin care,
Records showed that there were control measures in place for medicine stock levels and that overall people received their oral medicines. However, some people had not received all of their medicines because some had been unavailable and had not been obtained in time.
Shifts sometimes short staffed, even if overall numbers are now enough,
Four of the five care staff spoken with, two people using the service and two relatives told us shifts could sometimes run short of staff.
AI Generated
Last inspected: June 2022
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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