Last updated: 9 February 2026
"Trained staff and a caring culture support people well, but no registered manager and weak governance missed safety issues with medicines, risks and records."
There was a lack of protocols to guide staff when they should be administered [PRN medicines]. Most risk assessments were in place but had not always been regularly reviewed... Regular fire safety checks were completed, though we found fire drill records needed further detail.
There was a caring, positive culture at the service and most people, and their relatives were happy with the service provided. Staff were supported by the provider and the manager and were positive about the changes made since the manager had been in post.
There were sufficient numbers of staff to keep people safe and to meet their needs in a timely manner. We received mixed feedback about staffing levels. The provider was actively trying to recruit more permanent staff and where possible, used regular agency staff to support staffing levels.
People were supported by trained staff with the skills and knowledge to meet people's needs safely and in a timely manner. Staff received an induction and completed regular training to ensure they were able to meet people's needs. Staff were positive about the training provided.
At the time of our inspection there was not a registered manager in post. A new manager was in place at the time of the inspection and had started the process to register. The provider had failed to ensure governance systems were robust and effective to identify shortfalls in the service.
Per 2018 comprehensive inspection: People's activities were planned with them by the activities co-ordinator and a plan was devised. The activity schedule showed activities would take place each week day... linked with a local school and children and service users were paired.
No permanent manager in place, and quality checks missed problems with medication guidance, risks, fire records, and recruitment files.
At the time of our inspection there was not a registered manager in post... The provider's quality assurance systems needed further improvement... had not identified the shortfalls we found with medicines and records relating to risk management, fire and recruitment.
Gaps in risk assessments for things like catheters, lack of guidance on when to give as-needed medications, and incomplete fire drill records.
We found one person had a catheter. However, a relevant risk assessment was not in place... there was a lack of protocols to guide staff when they should be administered [PRN]... fire drill records needed further detail to allow for effective monitoring.
Staffing is adequate to keep people safe but gets mixed feedback on levels, and they use regular agency staff while trying to hire more permanents.
We received mixed feedback about staffing levels... The provider was actively trying to recruit more permanent staff and where possible, used regular agency staff to support staffing levels.
AI Generated
Last inspected: January 2023
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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