Last updated: 10 February 2026
"Staff feel supported with good training and varied activities, but safety issues like medication errors, unclean areas and overnight staffing shortages need fixing."
The service was in breach of legal regulation in relation to safe care and treatment, management of medicines, IPC and good governance. Issues with medication gaps, covert meds, unclean areas and environmental hazards.
Staff spoken with were positive about their employment within the service. Staff felt well supported in their roles and were positive about the new manager and the changes that had been made.
We have recommended a review of staffing levels within a unit of the service to ensure there were adequate staffing levels to meet the needs of people. Mixed feedback from relatives about not enough staff overnight.
Staff received an induction with access to a range of training courses.
A new manager had commenced in post in June 2025 and had made positive changes to the service since their start date, however, there were some areas of improvement identified during the assessment.
A range of activities took place to meet people’s preferences. This included baking, reading groups, music events, and pop art sessions. Observed people taking part in a pizza making class.
Not enough staff at times especially overnight, leaving others unsupervised during hoist care.
Not all the time, there are only two staff members and some residents need hoisting so there is no one left with other residents.” and “night time doesn’t seem to have as many.”
Medication errors like not giving time-sensitive meds on time and poor records for hidden medication.
We reviewed the records for one person who was prescribed time-sensitive medications and identified these were not consistently administered as prescribed with many gaps. The use of covert medication was not always clearly documented.
New manager is making changes but oversight missed unclean areas, medication problems and hazards.
Governance systems in place reviewed aspects of the service, however, some of the findings of this assessment had not been identified.
AI Generated
Last inspected: May 2021
Management Quality
Well-led: Good
Direct feedback from current and former employees

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