Last updated: 10 February 2026
"Staff receive regular training in an open culture with lively activities, but medicines safety issues and weekend staffing shortages are concerns."
Provider remained in breach of regulation 12... staff did not always consider medicines' dispensing instructions... staff crushed a person's medicines... without making sure it was safe to do so... Some risk assessments lacked details.
There was an open and inclusive culture at the service... Staff felt supported in their roles and told us they were able to speak up and raise concerns, if they had any. Staff also said teamwork had improved.
Feedback from some people and some relatives indicated there was not always enough staff on shift... 'They have lots of agency staff at weekends, I don't think they have enough staff.'
Staff received a comprehensive induction when they started work. This included completing mandatory training and working under the supervision of experienced staff. Staff also received regular training in a wide range of areas.
Provider remained in breach of regulation 17 (Good governance); audits not always effective as they had not identified most of the issues we found around safe management of medicines and assessing people's risks.
Activity coordinators, with the support of other staff, planned and delivered activities to people. We observed group activities which were lively... 'We do exercise and singing... I like artwork.'
Medication errors like crushing tablets without checking and gaps in risk monitoring charts mean safety isn't reliable.
staff crushed a person's medicines due to their swallowing difficulties without making sure it was safe to do so... Some risk assessments lacked details... gaps in their bowel charts.
Not enough staff at times, especially weekends with lots of agency workers, so the team feels stretched.
'I'm not sure they have enough staff especially at the weekends' and 'They have lots of agency staff at weekends'
Managers' audits and checks miss problems with medication and risks, so the same issues keep coming up.
audits were not always effective as they had not identified most of the issues we found around safe management of medicines and assessing people's risks.
AI Generated
Last inspected: November 2022
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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