Last updated: 10 February 2026
"Staff enjoy a positive culture with engaging activities and good teamwork, but safety risks, medicines management gaps and governance shortfalls hold it back."
breach of regulation 12, in relation to safe care and treatment, over concerns around assessing risks to people’s health care and safety and medicines management.
Staff told us they enjoyed working at the service. Their comments included, “I love coming to work and working here; It's rewarding to know I make such a difference to someone's life” and “We don’t have issues with each other, we talk and support each other.”
The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.
Staff received training in a range of areas to remain knowledgeable in their roles, but there were gaps in training monitoring systems.
we found inconsistencies and shortfalls in the governance of the service, including the effectiveness of quality assurance systems. These concerns amounted to a breach of regulation in relation to safe care and treatment, and a repeated breach of regulation regarding good governance.
An activity coordinator, who knew people well, visited the service regularly and together with the assistance of care staff, supported people to participate in their preferred activities... We observed staff engaging with people in a lively and cheerful singing and dancing group session... Staff also supported people in individual activities, such as puzzles.
Risk assessments and medication processes have gaps like missing guidance on when to give painkillers and no dates on opened liquids, so care might not always be safe.
PRN protocols containing guidance on when to administer these medicines were not in place... Staff did not record the opening dates for these medicines... an expired medicine box that was stored in the medicines cabinet.
Quality checks are not picking up problems like incomplete risk assessments and medication errors, with repeated governance failures.
existing quality assurance systems had not identified the issues we found in this assessment, including issues around assessing risks to people, medicines management and care planning... repeated breach of regulation 17, in relation to good governance.
Training records have discrepancies and the system for tracking it is not reliable.
there were gaps in training monitoring systems... discrepancies in staff training records.
AI Generated
Last inspected: October 2025
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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