Last updated: 10 February 2026
"Staff receive good training and supervision in a positive culture, but leadership oversight missed key safety issues like wrong pressure mattress settings."
Where people were at risk of pressure ulcers, airflow mattress settings were not correctly set based on their weight. For example, 2 people's pressure relieving mattresses were set to 150kg, despite their individual weights being significantly less.
We observed positive interactions between people and staff. Feedback we received about support from the registered manager was positive.
There were sufficient numbers of day time staff to meet people’s needs. Following our inspection, night time staffing levels were reviewed by the provider and increased to provide additional support.
Staff received formal support through training and supervision sessions. High training completion rates were noted in the November 2022 staff meeting.
Gaps were found in identifying shortfalls in some quality standards. We found there was insufficient oversight of the process of recording people's capacity which had not been identified before our inspection.
Residents meetings had taken place in August and November 2022 and showed people were engaged in a wide range of activities and events.
Managers checks missed key issues like wrong pressure mattress settings and mental capacity records, so leadership oversight has gaps.
Gaps were found in identifying shortfalls in some quality standards. We found there was insufficient oversight of the process of recording people's capacity which had not been identified before our inspection.
Pressure mattress settings were wrong for some people and put them at risk of sores until fixed during the inspection.
airflow mattress settings were not correctly set based on their weight. For example, 2 people's pressure relieving mattresses were set to 150kg, despite their individual weights being significantly less. This was addressed between days 1 and 2 of our inspection.
Night shifts started with too few staff, rushing people into bed early, though more staff were added afterwards.
concerns around people being encouraged to go to bed before night staff arrived was identified during the inspection... following our inspection, night time staffing levels were reviewed by the provider and increased
AI Generated
Last inspected: March 2023
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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