Last updated: 10 February 2026
"Positive culture and community activities with enough staff, but poor management oversight and unsafe medicines handling are concerns."
Medicines were not always managed safely. Some medicines were overstocked. Opening dates were not added to medicines... People's health related risks were not always assessed to provide guidance for staff to support people safely.
There was a positive and empowering culture at the service. Staff knew people and their aspirations and supported them to live a quality life of their choosing. One told us "I absolutely love my job, it's all about the people."
The service had enough staff, including for one-to-one support for people to take part in activities and visits how and when they wanted. The numbers and skills of staff matched the needs of people using the service.
Positive behaviour support (PBS) plans were in place for some people using the service. However not everyone had a PBS plan in place, but a behaviour support plan which did not always follow the same principles of PBS.
Management did not demonstrate effective oversight of key risk or quality of the service. Audits were carried out but had not identified issues found during our inspection.
The service had good links with the local community, and people got involved with various projects and events. One person told us about a food and drink festival they had attended, another was involved in a conference... visit a nearby farm and art project.
Managers do not oversee things closely enough, their audits missed problems like too much medicine stock.
Audits were carried out but had not identified issues found during our inspection. For example, a medicine audit completed had not picked up on excessive stock.
Health risks like seizures are not always properly assessed for staff guidance, and medicines are not handled safely with overstocking and recording errors.
People's health related risks were not always assessed... an epilepsy care plan or risk assessment for 2 people known to experience absence seizures was not in place... Medicines were not always managed safely. Some medicines were overstocked... we identified one recording error.
Staff do not have consistent training on behaviour support, some people lack proper evidence-based plans.
Some people's care and support had been assessed using positive behavioural support (PBS), whilst others hadn't... not everyone had a PBS plan in place... working with relevant professionals and seek training to address this.
AI Generated
Last inspected: November 2023
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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