Last updated: 10 February 2026
"Staff feel supported with good teamwork and solid training, but staffing shortages on the nursing unit and safety risks hold it back."
Risks to people’s health and safety were not always effectively assessed, monitored and mitigated. This included risks associated with skin integrity and insufficient fluid intake. For example, 6 people’s pressure relieving mattresses were not set to the correct weight.
Staff demonstrated good teamwork and there were fewer agency staff, with more regular staff working together. Most staff told us there were improvements in how well supported they felt and the provider gave them flexibility to balance their work/life responsibilities.
The provider did not make sure there was suitable deployment of enough staff to meet people’s needs. Staff were not adequately deployed to ensure people’s needs were effectively met. This was particularly evident on the nursing unit and at peak times during the day.
Staff training for medicines was up to date for almost all members of staff who required it. Staff training and competency was checked for administering medicines annually.
Aspects of quality assurance systems and processes had improved. However, they were not always effectively implemented to ensure safety or to drive improvement. Shortfalls identified through the assessment process had not always been identified or sufficiently addressed through the management team’s quality checks.
People were invited and supported to take part in group and individual activities. The activities team was being expanded at the time of the assessment to provide more opportunity for people to engage in meaningful occupation.
Not enough staff, especially on the nursing unit and busy times, so you get stretched, miss breaks, and can't help people right away.
Staff were not adequately deployed to ensure people’s needs were effectively met. This was particularly evident on the nursing unit and at peak times during the day. Staff did not have sufficient opportunity to take their breaks.
Risks like bed sores from wrong mattress settings or missed position changes aren't always handled properly.
6 people’s pressure relieving mattresses were not set to the correct weight and 3 people had not been repositioned in line with their assessed needs. On 1 occasion they had not been repositioned for over 46 hours.
Managers do quality checks but miss big problems like unreported serious injuries.
we found an example of a serious injury that had not been reported to the local authority or the Care Quality Commission. This had not been picked up by the provider’s internal quality checks.
AI Generated
Last inspected: November 2025
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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