Last updated: 10 February 2026
"A supportive friendly team and good training, but low staffing leaves high fall risk areas unsupervised and safety risks like falls and medication unaddressed."
We found two breaches of the legal regulations in relation to safe care and treatment and governance; measures around medication were not robust and staff did not always assess risks or mitigate them.
Staff felt there was a listening culture, were confident their voices were heard, and advised they were a supportive and friendly team who worked well together.
We were not assured the staff numbers and skill mix were always adequate to give people the care and support they needed and keep them safe, with observations of no staff in lounge areas with high fall risk people and unexplained falls.
The training matrix showed staff had completed a range of training, including dementia awareness, with evidence of compliance discussed in team meetings and access to enhanced training if requested.
Staff told us the registered manager was approachable and caring, and 'is fair, she is supportive of the staff, she listens to any concerns we might have'; however, governance systems and audits were not effective in identifying or addressing areas for improvement.
An activities coordinator was employed who contacted various outside communities to visit.
Staff numbers are sometimes too low, leaving rooms with high fall risk people unsupervised and causing unexplained falls.
We observed on 17 June 2024 and 12 July 2024 where there was no member of staff in the conservatory or lounge areas. There were people in these areas who were reported to be a high risk of falls.
Risks like falls and health needs are not always fully assessed or acted on, and medication is not always handled safely.
Staff did not always assess risks to people's health and safety or mitigate them where identified. People did not always have care plans to guide safe practice.
Management checks and audits miss key problems like incomplete care plans and unsafe practices.
Governance systems and audits were not effective in identifying or addressing areas for improvement.
AI Generated
Last inspected: October 2024
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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