Last updated: 10 February 2026
"Strong training and regular supervision help staff feel supported, but poor medicines safety, weak governance, and falling staff numbers create heavy workloads."
Medicines optimisation Score:2... Medicine administration and governance was not managed safely... breach of regulation 12 safe care and treatment... delays in the reporting and investigating of incidents and safeguarding concerns
Annual staff feedback report found that most staff would agree that the service promoted workplace wellbeing... However, some staff we spoke with, expressed concerns with the recent drop in staffing levels having an impact on workload and work culture
Safe and effective staffing Score:3. The service had a 37.5% decline in staffing levels over the year which raised concerns... The service had been able to cover shifts with agency staff... some staff... expressed concerns with the recent drop in staffing levels having an impact on workload
Training records for the service indicated 100% staff training compliance in mandatory areas including Learning Disabilities, Moving and Handling, Health and Safety and Infection Prevention and Control... Supervision records showed all staff had regular supervision meetings
Governance, management and sustainability Score:2. The service did not always have clear systems of accountability and good governance... breach of Regulation 17 (Good Governance)
Medication charts have gaps, wrong doses for pain relief, and allergy details wrong, risking choking or harm and not fixed after audits.
PRN protocols did not accurately reflect the prescribed doses... gaps in MARs... discrepancies in the recording of allergies... We found similar issues during the on-site visit
Staff numbers dropped by 37.5 percent so they use agency to cover and staff do long 14-hour shifts sometimes without breaks recorded, leading to heavy workloads.
The service had a 37.5% decline in staffing levels over the year... cover shifts with agency staff... some staff we spoke with reported working long shifts of 14 hours without adequate break time... allocated break times for staff were not recorded
Managers ignore audit findings and delay action on safety problems like poor incident reporting and record errors.
Despite internal audit identifying some concerns in August 2024 and a subsequent external audit... highlighting similar issues, we found little improvements were implemented... we found comparable concerns on our site visit day
AI Generated
Last inspected: February 2025
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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