Last updated: 10 February 2026
"A positive culture where staff feel supported and sufficient staffing meet needs, but incomplete training and weak governance hold it back."
incidents were recorded inconsistently and not in line with the provider’s procedure. Some of the incident records we reviewed were incomplete.
There was a positive culture within the service, staff told us they felt supported, people and their relatives spoke positively of their experiences.
We observed there was sufficient staff available to meet people’s needs, which was confirmed by feedback from people, relatives and staff.
records showed not all staff had completed or refreshed their required training.
in relation to good governance, we did not identify sufficient improvement, and the provider remained in breach of this regulation.
one person who attended a local gardening group looked after plants in several spaces around the service.
Training updates are not complete for all staff, so there are gaps in skills and knowledge.
records showed not all staff had completed or refreshed their required training.
Incident records are spotty and incomplete, and medication checks miss things like risk assessments.
We identified several incidents documented within care notes on the electronic care planning system which had not been formally recorded as incidents. Some of the incident records we reviewed were incomplete and were not signed off by management in a timely way.
Audits and oversight are weak, so issues like training and meds slip through without fixes.
Audits completed at service level did not identify or address shortfalls found during this assessment.
AI Generated
Last inspected: October 2025
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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