Last updated: 10 February 2026
"Staff feel able to speak up and raise concerns, but unsafe medicines management and frequent agency staff with inadequate training hold it back."
Medicines were not safely managed. The management of medicines was unsafe and posed risks to people. There was a failure to use appropriate equipment to move and handle 1 person safely.
Staff shared that they felt able to speak up, but many chose to raise concerns with administration staff rather than the management team. Staff said they attended meetings, but often felt the focus was on what they weren’t doing well.
Concerns were raised about agency staff, including a lack of understanding of roles and inadequate training in moving and handling. Up until a couple of weeks ago, I'd say we'd have an agency staff member on every week.
Staff required additional training to strengthen their understanding of contemporaneous documentation requirements and to enhance their confidence in using the electronic care planning system effectively. Feedback regarding training on the use of the electronic care planning system, was mixed.
While staff felt able to raise concerns, these were not always communicated directly to the management team, highlighting an area where further encouragement and support could be provided.
Feedback on access to social activities was mixed, indicating that while some opportunities were available, further development in this area could enhance people’s overall experience. Several noted that the range of activities felt limited.
Medication given wrongly like missed pain patches and thickened fluids not recorded, putting people at risk.
We found one person had not had their pain relief patch applied when it was due to be changed... Staff did not always record when thickened fluids were being given to people who were at risk of choking.
Frequent agency staff who don't know the home or tasks well, making care slower and harder.
Up until a couple of weeks ago, I'd say we'd have an agency staff member on every week... agency senior that didn't know the floor as well as other staff.
Staff training gaps on electronic records and documentation, with some unable to use the system properly.
Several staff indicated they either lacked access to care plans or were unfamiliar with the system. Feedback regarding training on the use of the electronic care planning system, was mixed.
AI Generated
Last inspected: March 2019
Management Quality
Well-led: Good
Direct feedback from current and former employees

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