Last updated: 9 February 2026
"Good staff training and positive culture shine through, but medicines errors and unreliable leadership oversight need fixing."
The provider had made improvements since our last inspection to the management of people's medicines, however further oversight was required to ensure people received their medicines safely. People did not always receive their eye medicine in line with their prescribing instructions.
Staff shared a positive culture which provided good outcomes for people. Staff were encouraged to be open and honest when things went wrong.
There were enough staff to meet people's needs. People were supported by permanent members of staff, the manager told us they now only used one occasional agency nurse.
Staff now had the right training to meet people's needs. Staff we spoke with confirmed they received the right training and information to support people.
At the time of our inspection the manager was in the process of registering with us. The manager demonstrated an oversight of the service with significant improvements made since our last inspection, however the changes made required further embedding.
The provider had an activity coordinator who supported people two days every week with stimulation and different activities of their interest. People were supported to take part in activities which were of interest to them on a one to one basis.
No permanent registered manager yet and quality checks miss issues like care plan gaps or medicine errors, so leadership oversight feels unreliable.
At the time of our inspection the manager was in the process of registering with us... The systems in place were not robust enough to identify required updates or improvements.
Medication errors happen like giving out of date eye drops for eight days straight or wrong timing between doses.
We found one person had received an out of date eye medicine for eight consecutive days... Staff did not always administer people's medicines within the required time interval.
Some staff hired without full checks like missing references from last job or gaps in work history.
Staff did not always have required checks in place prior to their employment. One staff file did not contain a reference from their most recent employer. We also saw gaps in another staff member's employment history.
AI Generated
Last inspected: June 2022
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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