Last updated: 10 February 2026
"Positive staff morale and varied activities, but weak safety in incident handling, risks, and medicines management."
Breach of Regulation 12; risk management for emotional needs not robust; medicines shortfalls in storage, PRN protocols, and administration recording; no debriefs for critical incidents.
Staff reported positive morale, working as a family with open communication and confidence to raise concerns, though limited formal learning from incidents.
Sufficient staff overall matching commissioned hours but 10 occasions Aug-Nov 2024 below hours; agency used as last resort but not assured fully trained in behavioural strategies and crisis management.
Training matrix showed some gaps with ongoing refreshers planned; staff had not received supervision at the frequency expected; concerns raised about crisis support training.
Staff praised registered manager as approachable with open door policy, but governance breached Regulation 17 with shortfalls in incident management oversight and staff supervision frequency.
Varied community activities including rock climbing, snowboarding, farm/gardening project, day trips to seaside, zoos, shopping, planned via monthly keyworker meetings.
Handling of incidents and risks is weak with no team debriefs after serious events, and problems storing and giving medicines safely.
the provider had failed to follow their incident management procedure... procedures were not sufficiently robust... Medicines management needed improvement, this included how medicines were stored and administered. Protocols for medicines prescribed to be administered when required were not sufficiently detailed.
Sometimes short staffed below funded hours and agency workers may lack full training for handling crises.
Records showed there had been 10 occasions between August and November 2024 when staffing was less than the hours commissioned... we were not sufficiently assured they were fully trained in accredited behavioural strategies and crisis management the provider used.
Gaps in training records and staff not getting supervision as often as they should.
The staff training matrix showed some gaps in training... Staff had not received supervision at the frequency the provider expected.
AI Generated
Last inspected: March 2018
Management Quality
Well-led: Outstanding
Direct feedback from current and former employees

Scan the QR code or tap the button to chat with us on WhatsApp. Your identity stays completely anonymous.
Chat on WhatsApp