Last updated: 10 February 2026
"Staff feel supported with good training and activities, but low staffing, medicines issues and weak management hold it back."
Medicines administration records' (MAR) were not always completed in line with best practice... The provider's medication policy did not include information relating to 'when required' (PRN) medicines
Staff felt well supported by the management team. They told us, '[Registered manager] comes in, wants to do what's right by people. It's been great, I feel I can ask any questions.' Staff described a positive working culture
Relatives told us that challenges in staffing levels meant that people could not always complete planned activities in the community. Staff told us that staffing levels had impacted some activities
Staff completed an induction programme when they joined the service... Staff received support in the form of continual supervision, appraisal and recognition of good practice
Systems were either not in place or robust enough to demonstrate risks to people's physical health was mitigated and restrictions on people were appropriately assessed. This placed people at risk of harm. This was a breach of regulation 17
People's interests were reflected in care plans. This included a weekly schedule of activities the person took part in, in the home or out in the community which included social groups. The provider organised personalised events
Staff numbers are sometimes too low, so you can't always take people out for planned activities.
Relatives told us that challenges in staffing levels meant that people could not always complete planned activities in the community. One shared, 'It has improved more recently, [Person] has been stuck in the house'
Medication records are not always complete or accurate, and the policy misses guidance on as-needed meds.
Medicines administration records' (MAR) were not always completed in line with best practice to ensure they were accurate and contained detail regarding directions for use for medicines prescribed occasionally
Leadership oversight is weak with gaps in mental capacity records for restrictions like smoking or food access.
Decision making for people did not always clearly evidence that appropriate legal authorisations were in place. For example, 1 person's care plan stated they had restrictions on the number of cigarettes available to them. Consideration of MCA in relation to this restriction was not evidenced
AI Generated
Last inspected: July 2023
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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