Last updated: 9 February 2026
"Staff feel supported like family in a friendly team, but medicines safety errors, incomplete recruitment checks and training gaps hold it back."
The registered manager did not always ensure safe care and treatment, and risk management. The management of medicines needed improvement... Risk assessments were not consistently followed... We found 7 unboxed insulin pens... homely remedies... staff were applying emollients that were not listed... Incidences were not always recorded and logged.
Most staff felt they could approach the management team for support and advice or raise concerns and issues... Staff said, “It can be very busy, but we support each other well. My team are very good, like a family” and “It is a friendly home. I’ve always felt part of team.”
Feedback regarding staffing numbers was mixed... When people’s call bell rang, staff did not always respond promptly. For example, one person was shouting for help, the call bell was ringing but we could not see any staff... In 5 staff files we found discrepancies with gathering information of full employment history... necessary Disclosure and Barring Service (DBS) checks were not always completed prior to staff commencing work.
Review of training matrix indicated not all staff were up to date or completed training topics. For example, there were people who had diabetes or a catheter however not all staff had such training.
Governance and oversight of the service and its quality needed improvement. The registered manager did not always ensure the issues we found during this assessment were identified through their own quality monitoring systems.
There was an activities programme but there were periods when staff did not ensure people were engaged in activities to avoid social isolation... we observed people were involved in some activities but there was a lot of time spent when people did not do much.
Recruitment checks are incomplete with missing DBS and job history gaps, and staffing is stretched with unanswered call bells and one staff covering too many at lunch.
In 5 staff files we found discrepancies with gathering information of full employment history and unexplained gaps... necessary Disclosure and Barring Service (DBS) checks were not always completed prior to staff commencing work... When people’s call bell rang, staff did not always respond promptly... there was only 1 staff who was supporting 13 residents.
Medication handling has errors like unlisted insulin pens and giving thin fluids to someone needing thickened ones, putting people at risk.
We found 7 unboxed insulin pens for one person... not listed as current medicine... one person’s risk assessment for choking... required level 1 thickened fluid... on multiple occasions this person was given ‘thin’ fluid consistency.
Training has gaps so not all staff are up to date on key needs like diabetes or catheter care.
Review of training matrix indicated not all staff were up to date or completed training topics. For example, there were people who had diabetes or a catheter however not all staff had such training.
AI Generated
Last inspected: March 2025
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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