Last updated: 10 February 2026
"Staff feel supported with great teamwork and sufficient staffing, but medicine management issues and ineffective quality checks need attention."
Continued breach of regulation 12: medicine management issues including MAR gaps, single signatures instead of two, unclear PRN protocols and missing records.
Staff felt supported and believed they had maintained great teamwork; quotes like 'fantastic place to work, nice team work'.
Staff reported they felt staffing levels were sufficient to enable safe and effective practice; some agency use for consistency due to vaccination changes.
Per 2020 comprehensive inspection: staff had up to date mandatory training, but provider policy for refreshers (e.g. safeguarding every 3 years) not aligned with best practice guidelines.
Staff felt the registered manager was managing the service well, and they were accessible and open with the staff members, but 'the registered person was still in breach of regulation 17 (Good governance)' due to ineffective quality assurance systems.
Per 2020 comprehensive inspection: people supported with community outings and interests, but staff in 2021 noted 'we need to do more in some areas like activities due to pandemic'.
Medication errors like missing signatures on records and unclear instructions for as-needed pain relief put people at risk.
We found on seven occasions only one staff member signed the MAR sheet after administration of medicine instead of two; PRN protocols did not always contain clear information specific to the person.
Managers oversight missed problems with meds and records because quality checks werent picking them up.
the registered manager did not identify issues we found during inspection using weekly and monthly medicine audits; the system did not work effectively to ensure safe management of medicine.
Staff say they need to do more activities and engagement because of the pandemic restrictions.
we need to do more in some areas like activities due to pandemic, engaging with the people we support.
AI Generated
Last inspected: February 2022
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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