Last updated: 10 February 2026
"Positive staff culture and enough staffing support people safely with good activities, but poor medicines management and weak governance need urgent fixes."
The management of medicines was not always safe and people were at risk of not always receiving their medicines as prescribed. The provider had not ensured the safe management of medicines. This was a breach of regulation 12.
We found that although effective management systems were lacking, there was a positive culture amongst staff.
There was enough staff to support people safely and people confirmed this. One person told us, 'I feel safe here, definitely, there are plenty of staff.'
Staff received training and support to be effective in their role, although some improvements were needed in carrying out competency checks. For example, there was no evidence that staff had their competencies checked in administration of topical creams.
The providers' governance systems had not identified the shortfalls found at this inspection. Audit systems and processes failed to identify and manage effectively risks.
People were supported to take part in activities such as bingo, skittles, music sessions, hand massage and gardening.
Medication management has big problems like missing checks, records and signatures, so staff risk giving wrong doses or missing doses altogether.
There were missed signatures on MAR charts, and we were unable to determine if people had been administered their medicines or not... Failing to ensure people received their medicine as prescribed placed people at increased risk of harm.
Managers' audits and oversight missed safety risks like medicine issues and poor incident follow-up.
The providers' governance systems had not identified the shortfalls found at this inspection. Audit systems and processes failed to identify and manage effectively risks relating to the management of medicines.
Staff training misses checks on key skills like applying creams, so some care might not be done right.
Staff administering topical creams had no competency checks to ensure they applied people's creams correctly... some staff would benefit from additional training; for example, in management of medicines.
AI Generated
Last inspected: September 2023
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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