Last updated: 9 February 2026
"Stable staffing and supportive managers help staff feel valued, but unsafe medicines management and weak safety checks create serious risks."
Medicines were not managed safely. Some prescribed medicines were not administered in line with national guidance, for example high-risk medications were not clearly included in care plans.”
Staff told us they felt valued and listened to, and their views were considered when decisions were made. Comments included, I have a very supportive management team.”
Safe staffing levels were maintained throughout the service. The service had a long-standing staff group which promoted continuity of care and helped build trusting relationships with people.
Staff had completed induction and refresher training, ensuring their skills and knowledge remained up to date. Records showed regular supervisions and appraisals.
Staff said they felt supported by managers, who were described as fair, approachable, and responsive to concerns. The registered manager was experienced and had the skills, knowledge, and credibility to lead effectively.
People had access to meaningful activities and took part in social interests. The service utilised a wide range of community groups to enhance people’s wellbeing and social inclusion.”
Medication handling has gaps like missing protocols for high-risk drugs and blank charts, making daily meds rounds riskier for staff and residents.
Some prescribed medicines were not administered in line with national guidance. For example, high-risk medications were not clearly included in care plans... Medicines administration records (MAR) for thickeners were blank
No review of accident patterns or team debriefs means safety lessons are not shared, so problems can repeat on your shifts.
there was no evidence of trends and patterns identified to mitigate future risks and no records of debriefing after accidents and incidents.”
Weak audits and oversight let risks like unsafe meds slip through until pointed out, adding unexpected pressure to staff.
audits to monitor the quality of the service and identify areas for improvement were not consistently completed. As a result, the provider had not always identified or acted on concerns relating to... medication safety.”
AI Generated
Last inspected: November 2018
Management Quality
Well-led: Good
Direct feedback from current and former employees

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