Last updated: 9 February 2026
"Staff built positive relationships and had good training, but bosses lacked oversight during manager absences and activities were too basic."
Shortfalls in the management of medicines had been identified. However, further monitoring was needed to ensure the remedial action taken to address the shortfalls were effective.
Staff were knowledgeable and respectful of the person's diverse needs and it was clear from our observations they had developed a positive relationship with the person.
There were enough staff available to provide the support the person required. Staff had no concerns about staffing levels but explained staff being 'regularly' moved to work at one of the provider's other locations had a negative impact.
Staff completed a programme of training the provider considered essential, which was refreshed at regular intervals.
The provider had not maintained sufficient oversight of the service, whilst the registered manager had not been at work, to ensure compliance with the regulations.
One person told us they spent their time doing what they enjoyed and what was important to them. This included visiting family, attending church and going to the shops.
Bosses did not keep good watch over the home during manager absences, missing safety problems and leaving staff without guidance.
The lack of provider oversight, during a period of management instability at Lionsfield House, meant staff had not received the support and guidance they needed.
Some safety risks like fire hazards and medication recording gaps were not managed well enough.
Individual and environmental risk, including fire safety, was not always identified and well-managed... staff had not always completed medication administration records.
No activities coordinator or special programmes, so days are mostly routine care with basic outings to church or shops.
Staff understood the positive impact supporting the person to follow their interests and hobbies had on their mental health and well-being.
AI Generated
Last inspected: August 2022
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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