Last updated: 10 February 2026
"Strong training and positive culture, but serious safety issues with medicines management and poor oversight on risks like constipation hold it back."
The service was in breach of legal regulation in relation to people’s safe care and treatment and the ways people’s medicines were managed safely. Issues included stock counts not balancing, delays in receiving medicines, PRN laxatives not given for constipation.
Most staff gave positive feedback about the culture of the service. Staff reported a positive open culture where they felt empowered to raise any concerns or make suggestions. Comments included 'The culture is great'.
We observed there were enough staff on duty to support people. However, people gave us mixed feedback about the staffing levels including waits up to an hour in mornings and at night such as 'I rang at 06:00 and they came to me at 07.20'.
Staff had regular supervision meetings, induction was a mixture of training and shadowing... The registered manager was passionate about learning and supported staff to gain work related qualifications... Some staff had completed Care Home Assistant Practitioner training.
The service was in breach of legal regulation in relation to good governance. There had been a lack of clinical and management oversight of constipation risks because systems had not been embedded to review bowel charts.
There was a varied choice of activities available... bingo, singing, games, cinema, quizzes, art, crafting and reminiscence and was led by a mixture of internal activities staff, care staff and external entertainers. They have pets, these are good therapy.
Big problems with safety like people not getting laxative medicines when constipated for days and medicine stock not matching records properly.
Risks to people in relation to harm from constipation were not always well managed... A person had not opened their bowels for 10 days... stock counts of people’s medicines did not always balance with the records held.
Managers missed important oversight on risks such as not reviewing bowel charts or fully recording falls lessons.
There had been a lack of clinical and management oversight of constipation risks because systems had not been embedded to review bowel charts... When falls had occurred, the record did not always include all the relevant information.
Staffing causes long waits for help especially at night and busy mornings when everyone wants to get up.
A person told us there was not enough staff at night... Waited from 18:00 until 19:40 last night for a pad change... periods in the morning where they are obviously getting everyone out of bed. If you miss your slot you may have to wait up to an hour.
AI Generated
Last inspected: November 2025
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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