Last updated: 9 February 2026
"Staff feel supported with a positive culture and engaging activities, but serious safety lapses like missed repositioning and inaccurate medication records hold it back."
The service was in breach of legal regulation in relation to people’s safe care and treatment. People did not always receive support to reposition at their required frequency... remained in the same position for up to 10 hours. Medicines quantities not always input accurately.
Staff were positive about the service they provided, the management team and liked working there. Staff said they felt very supported by the management team.
People said there were enough staff to meet their needs. Staff said, “Staffing levels are generally well-managed to meet people’s needs,” but recruitment files lacked full information and oversight not robust.
We reviewed the training provided and saw this covered all mandatory subjects, however, some was due for renewal or needed to be completed. This also included for the registered manager.
The management team spent time around the home providing support and guidance. People, relatives and staff were positive about their presence, guidance and approach, but provider in breach of governance including statutory notifications and oversight of recruitment.
People were listening to music on the TV, having one to one chats, and joining in with a quiz. Another person was painting a gift... visiting entertainers and a local school. Buddi interactive activity and therapy system covering cognitive, music, physio and reminiscence.
Serious safety problems like missed repositioning putting people at risk of pressure ulcers and inaccurate medication records mean care can be unsafe.
All 4 had gaps in their required position changes or were repositioned on to the same body part... a person... remained in the same position for up to 10 hours during the day. We found quantities were not always input into the system accurately.
Recruitment records are incomplete with gaps in employment history and missing documents in staff files.
Staff files did not always include all the required information... gaps in employment were not identified and a record of people’s identification documents were saved as part of the file.
Some mandatory training is overdue and needs completing, including for the manager.
Some was due for renewal or needed to be completed. This also included for the registered manager.
AI Generated
Last inspected: October 2023
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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