Last updated: 9 February 2026
"Staff feel valued with supportive leadership and usually enough staff on duty, but serious safety issues like unsafe medicines and delayed safeguarding reports hold it back."
We found 2 breaches of the legal Regulations. The provider no longer had systems and processes in place for the safe use of medicines and people had not always been safeguarded from abuse... Medicines were being pre-dispensed by the night staff for the day staff to administer the following morning. This is not safe or good practice.
Most staff spoke of a positive, person centred, culture within the service and of a sense of trust and confidence in the skills of the leadership team who they felt were visible within the service, supportive and made them feel valued.
Most staff felt there were usually sufficient staff on duty... Some staff felt there were busy periods but explained that the provider had been responsive and added additional staff at weekends for example. Staff rotas were in place and showed that planned staffing levels were met.
Medicines training had expired for some members of staff and a refresher not undertaken in line with the providers policy. Medicines competency assessments whilst undertaken lacked detail.
The registered manager was aware [medicines were being pre-dispensed by night staff] but they had not taken steps to address this. The registered manager had not appropriately escalated a safeguarding concern to relevant agencies in a timely manner.
Per 2019 inspection: People were enabled to follow a variety of interests and activities. One person said, 'We go out and about sometimes. We play games and we have singers come in'.
Serious safety problems including medication errors like wrong doses and pre-pouring pills, plus delayed reports of possible abuse.
1 person prescribed a twice daily dose of pain relief, was on 7 days given this medicine 3 times a day and on 3 days received this 4 times a day. Medicines were being pre-dispensed by the night staff... A safeguarding incident had not being escalated to relevant agencies in a timely manner.
Leadership knows about safety issues like unsafe medicines and poor safeguarding but has not fixed them properly.
The registered manager was aware this practice was happening, but they had not taken steps to address this. The registered manager had not appropriately escalated a safeguarding concern to relevant agencies in a timely manner.
Gaps in mandatory training, especially medicines training not up to date for some staff.
Medicines training had expired for some members of staff and a refresher not undertaken in line with the providers policy.
AI Generated
Last inspected: September 2024
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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