Last updated: 10 February 2026
"Good training and positive culture, but high agency use, a manager too gentle with problem staff and medicines record errors hold it back."
Medicines gaps including 'rescue medication [not] evidenced on [MAR] chart' and discrepancies 'not identified in the services medication audit'; risk assessments lacked mitigation details.
'There was a positive culture within the service'; positive feedback from staff, relatives and stakeholders.
Enough staff to meet needs safely per relatives and observations, but 'a high number of agency staff working within the service'.
Staff reported 'service specific' training including 'epilepsy, midazolam, hoisting... giving medication and feed through a gastric tube'; online and classroom based.
Staff described the manager as 'amazing' but said '[manager] can be too gentle with staff we have a problem with'; audits ineffective at identifying record and medicine issues.
Basic engagement like local community access, cruise holiday, sensory equipment and relaxation room mentioned.
The manager gets praise from staff but is too gentle when sorting out colleagues who cause problems, and audits miss record issues.
Sometimes [manager] can be too gentle with staff we have a problem with, and she'll [speak with staff] but the member of staff continues to upset others... the service’s medication audit did not identify the concerns
Enough staff on duty but lots of agency workers means the team is not stable.
there are a high number of agency staff working within the service
Medication records have mistakes like missing rescue meds and wrong strengths that audits do not catch, plus unclear risk plans.
did not have their rescue medication evidenced on their medication administration record (MAR) chart... differed to the labelling instructions... not identified in the services medication audit... no information recorded on how this risk would be managed
AI Generated
Last inspected: August 2024
Management Quality
Well-led: Good
Direct feedback from current and former employees

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