Last updated: 10 February 2026
"Staff feel supported in a positive culture with decent activities, but poor leadership oversight, safety hazards, and stretched morning staffing hold it back."
The service was in breach of legal regulation in relation to poor infection control and the maintenance of the environment. Carpets that were degraded and frayed which were a trip hazard, a hot radiator with no cover risking burns.
Staff told us they felt supported and if they had any personal concerns they could approach the registered manager. We have always invited staff to operate an open door system.
People told us there were not always sufficient staff to support them. Staff we spoke to told us that there are only sufficient staff during the day as night staff were undertaking the majority of personal care for people in the mornings.
Whilst there had been improvements with the training since the last assessment, we found some gaps in the training records. There were ancillary staff that had not completed emergency first aid training. A newly recruited care staff had not completed face to face dementia training or Dignity in Care training.
Lack of robust management and provider oversight to review shortfalls of care. The service was in breach of legal regulation in relation to governance at the service.
There were mixed responses about the activities on offer. We play games in here, skittles and dominoes. Activities are good. I like Bingo stuff and music now and again.
Leadership has serious failings with poor oversight and audits that miss safety hazards and infection risks.
Neither the provider nor the registered manager had identified these concerns from audits they had undertaken. For example, we saw from the April 2025 reports of the visits by the provider, they stated The environment was clean, tidy, and free from obvious hazards.
Staffing is stretched in mornings because night staff do most personal care before day shifts start, so people lack choice on when to get up.
night staff were undertaking the majority of personal care for people in the mornings before they went off shift. Leaders had not considered whether more staff were required during the day, so people had more choice of when they wanted to get up.
Safety issues include poor infection control like urine smells and no handwashing sinks, plus trip hazards and unsafe storage.
When we arrived at the service there was a strong smell of urine in various parts of the service including 2 peoples rooms and lounges. In 1 sluice room, there was no sink for staff to wash their hands before leaving the room.
AI Generated
Last inspected: July 2025
Management Quality
Well-led: Inadequate
Direct feedback from current and former employees

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