Last updated: 9 February 2026
"A positive culture where staff and people speak well of the manager alongside safe staffing, but delays in time-critical medicines and ineffective management checks put people at risk."
People experienced delays in receiving time critical medicines... over 10 occasions where staff had administered their time critical medicine between 1-3 hours later than the prescribed time. This put the person at risk.
Staff and people told us there was a positive culture in the home and everyone spoke positively of the registered manager.
Staffing levels were safe.
Quality systems were not always effective in identifying issues relating to the management of time critical medicines, risk assessments and mental capacity assessments.
Time critical meds are often given 1 to 3 hours late, like over 10 times for one person, risking their health.
we reviewed one person's medicine administration record (MAR) for August 2023 and found over 10 occasions where staff had administered their time critical medicine between 1-3 hours later than the prescribed time. This put the person at risk from not receiving their medicine promptly to manage known risks associated with their health condition.
Managers checks and audits are not spotting key issues like late medication, weak risk assessments, and mental capacity paperwork.
Quality systems were not always effective in identifying issues relating to the management of time critical medicines, risk assessments and mental capacity assessments.
Staffing is safe and adequate but nothing special, with no info on low agency use or staff saying workloads are easy.
Staffing levels were safe.
AI Generated
Last inspected: November 2023
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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