Last updated: 10 February 2026
"Unstable leadership, heavy agency staff use, and missing key training caused staff confusion, exhaustion, and unsafe care."
The service was in breach of legal regulation in relation to safe care and treatment, medicine optimisation, safe and effective staffing.
Several staff members reported experiencing fatigue and burnout, which impacted their ability to deliver compassionate care.
There was a high reliance on agency staff, many of whom told us they had not read people’s care records and were unfamiliar with individual needs and risk management plans.
Staff had not received essential training or had their competency assessed by a clinical lead in both the safe management of acute health conditions and positive behaviour support.
Recent repeated changes in leadership caused significant confusion among staff teams, particularly around roles and responsibilities.
One person told us, “The weekends are boring. We don’t go out very often as they are struggling for drivers, so we don’t get to do what we want to or choose to.”
Not enough permanent staff with lots of agency workers who don't know residents well, leaving everyone stretched and exhausted.
significant gaps were identified... high reliance on agency staff... Several staff told us they felt emotional and exhausted
Unstable leadership with constant changes and no clear manager, so no proper oversight or direction.
I don’t know who the manager is because there are so many changes... Recent repeated changes in leadership caused significant confusion
Staff missing key training for handling distressed behaviours and health tasks like feeding tubes or seizures.
Staff lacked training, skills, knowledge and competencies to support people effectively to manage distressed behaviours and specific health care tasks
AI Generated
Last inspected: December 2018
Management Quality
Well-led: Inadequate
Direct feedback from current and former employees

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