Last updated: 10 February 2026
"Strong team spirit, good staffing and varied activities, but no permanent manager causes serious governance gaps."
We found some discrepancies between what was recorded on people’s medication administration (MAR) records and ‘when required’ (PRN) protocols. In one case, an antibiotic was not administered as prescribed... the process for the disposal of unused medicines [not compliant with] best practice guidelines.
Staff told us, “We have a strong team spirit and work collaboratively... My manager is approachable and he encourages sharing of ideas, raising concerns or suggestions.”
Staffing levels appeared to meet people’s needs... All staff, people and their relatives told us they felt staffing levels met people’s needs. Staff did not raise any concerns about the staffing levels at the service.
The provider did not always make sure staff received effective supervision and development, in line with the provider’s policy... 2 out of 3 staff had not received the required number of supervisions... not all staff had completed training in supporting people with a modified diet.
At the time of the assessment, there was no registered manager in post, and the service was being overseen by the nominated individual... the service was in continued breach of the legal regulation in relation to good governance.
We offer music sessions, arts and crafts, bingo, gentle exercise, themed days or celebrations, memory games or hobbies they enjoy. These activities are adapted depending on [people’s] abilities and preferences... The service’s activity timetable included seated arm exercises and seated exercises.
No permanent manager in post, so oversight and governance have serious gaps pulling everything down.
there was no registered manager in post... the service was in continued breach of the legal regulation in relation to good governance.
Staff miss some supervisions and training gaps like on modified diets mean support isn't always consistent.
2 out of 3 staff had not received the required number of supervisions... not all staff had completed training in supporting people with a modified diet.
Medication errors like missed doses and unclear disposal of refused meds create safety risks that audits miss.
an antibiotic was not administered as prescribed... the service had not ensured how they disposed of refused medicines was safe and appropriate... Audits took place regularly, but these had not identified the above concerns.
AI Generated
Last inspected: June 2025
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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