Last updated: 10 February 2026
"A positive culture with improved morale and reliable staffing, but unstable leadership and medication safety issues weaken oversight."
Risk assessments not always completed correctly... medicines administration systems not always managed safely and records inconsistent; contributed to breach of regulation 12.
Staff gave positive feedback about the changes... 'Everyone is pulling in the same direction, and the morale and culture has improved.' Relatives noted calmer atmosphere.
There were enough staff to meet people’s needs; the provider had introduced a dependency tool... relatives say 'There are always plenty of staff when I visit'.
Staff administering medicines had not received appropriate training or been assessed as competent; not all staff had received supervision or appraisal.
The changes in leadership over a short period of time impacted the quality of oversight and culture of the service; previous registered manager left, new manager also left shortly after.
Mixed feedback from relatives about activity provision; good quality with staff going extra mile like birthday party, but times when relatives bored with little stimulation; staff use app for tailored activities.
No permanent manager in place, with several recent changes leaving oversight weak.
The previous registered manager left the service, and a new manager was appointed. Shortly after the on-site assessment, the provider informed us the new manager had also left the service.
Medication mistakes and gaps in risk checks make the job riskier and more stressful.
Medicines administration systems were not always managed safely... multiple stock and administration errors... risk assessments were not always correctly completed.
Gaps in staff training and supervisions, especially for meds and dementia care.
Staff administering medicines had not received appropriate training or been assessed as competent... Not all staff had received supervision or appraisal... dementia care not always in line with best practice.
AI Generated
Last inspected: June 2025
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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