Last updated: 10 February 2026
"A positive culture, good training and engaging activities support staff well, but unreported safety incidents and missing risk assessments need urgent attention."
The registered manager told us there had not been any safeguarding concerns at the home, however we were informed by staff about incidents such as sexually inappropriate behaviour, altercations between people living at the home, and for one person a serious fall... These were not clearly documented anywhere within care records, and appropriate referrals had not been made.
Staff described a positive and open culture where they felt supported and able to raise concerns or suggestions. A staff member said, 'The culture here is why it works so well; it’s like family.'
Staff, people living at the home and relatives told us staffing levels were sufficient. One member of staff said, 'We have enough staff for now. The manager will help us when we are struggling.'
Staff told us they received enough training to support them in their role. A training matrix was in place showing which training courses had been completed. Staff supervisions and appraisals had taken place.
The provider was previously in breach of legal regulations regarding good governance. Improvements were found at this assessment, and the provider was no longer in breach of this regulation. However, we found further improvement was required with record keeping, the comprehensiveness of some people's care plans and risk assessments, and with the provider's governance processes.
Activities have included a Halloween celebration, tea parties, baking, keep fit, singalong and film days. Trips out have included visiting [venue name], and going to bowling clubs. The activity coordinator had a particularly good rapport with people.
Staff did not always report incidents like arguments, sexual behaviour or falls, or make safeguarding referrals on time.
we were informed by staff about incidents such as sexually inappropriate behaviour, altercations between people living at the home, and for one person a serious fall when out in the community. These were not clearly documented anywhere within care records, and appropriate referrals had not been made to the local authority.
Risk assessments were often missing for things like choking, skin sores or self-medicating with insulin.
Risk assessments were not in place to demonstrate how these risks would be managed appropriately... one person had a moisture lesion but did not have an appropriate skin integrity care plan in place.
Governance checks did not catch gaps in records or plans until inspectors pointed them out.
further improvements were necessary to ensure audits were more robust in identifying any gaps, and the improvements made during this inspection needed to be sustained over a longer period.
AI Generated
Last inspected: February 2024
Direct feedback from current and former employees

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