Last updated: 9 February 2026
"Staff feel valued and supported with improved staffing and training, but safety lapses in turning people and medicine records need fixing."
The provider did not always work with people to understand and manage risks... for some people, who were at risk of pressure ulcers, were not always repositioned within the agreed time... gaps in medicine charts and stock control, so we could not be assured people had received their prescribed medicines.
Staff described feeling valued and supported, citing the “open door” policy and daily huddles... A staff member said, “It is a really good home. Things have dramatically improved, and we are kept up to date.”
Staffing levels had improved since our last inspection. There was increased night staffing and reduced agency use. Staff felt supported and valued... One staff member said, “There are enough staff. It has gotten much better.”
Training was accessible and tailored, with competency checks in place. Staff praised the manager’s leadership and the positive culture within the service.
Governance systems had improved but remained inconsistent, with gaps in oversight and monitoring that led to missed checks and documentation issues. This resulted in a breach of legal regulation under the well-led key question in relation to governance systems and processes needing improvement.
People had access to meaningful activities tailored to their interests. Despite the lift being out of order... staff adapted the activity schedule... activities coordinator for “going above and beyond,” including organising a special birthday outing and celebration. People also enjoyed trips out in the service’s minibus and visits from community groups.
Staff did not always turn people at risk of skin sores from lying too long within the right time, which raises safety risks even though no one was harmed.
for some people, who were at risk of pressure ulcers, were not always repositioned within the agreed time to ensure their skin remained intact. While we found people were unharmed due to these delays, it significantly increases the risk of skin damage.
Medication records had gaps and poor stock checks, so it's unclear if everyone got their meds on time.
we found gaps in medicine charts and stock control, so we could not be assured people had received their prescribed medicines. However... there was no evidence anyone had come to harm.
Bosses' checking systems miss key things like turning records and consent forms, so problems slip through.
there were gaps in governance systems where key checks and monitoring activities had been missed. We found some people who needed positional changes... had gone beyond 4 hours and monitoring systems had not identified this. Some people did not have their consent recorded.
AI Generated
Last inspected: July 2023
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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