Last updated: 9 February 2026
"Stable staff team and supportive culture with good training, but weak governance and safety gaps like missing reports need attention."
Safeguarding concerns not notified to CQC, incident reports lacked detail on actions taken, gaps in risk assessments for emollients and blood thinning medicines, medicines recording needed review.
Staff worked well as a team and enjoyed working at the service; staff said they felt valued, supported and part of an effective team.
The service had a consistent, stable staff team who knew people well; people and staff told us there were enough staff available.
Staff received an induction, supervision and a range of training including moving and handling, first aid and person-centred care with competency checks; staff were supported to develop qualifications.
Governance systems had not identified areas found at this assessment including omission of safeguarding notifications, mental capacity assessments not completed for specific areas, and no improvement plan to demonstrate areas for development.
Activities coordinator managed small group and individual activities; observed craft making, exercises, quizzes and positive feedback from people.
Managers did not spot problems like missing safeguarding reports to the regulator, incomplete mental capacity checks for things like bed rails, and gaps in care plans, so leadership oversight is weak.
Governance systems had not identified areas found at this assessment. Including the omission of safeguarding notifications submitted to the Care Quality Commission (CQC), mental capacity assessments and best interest decisions not being completed for specific areas where people lacked capacity to consent to care.
Safety records have gaps like not detailing actions after incidents or risks from creams and falls on blood thinners, so reporting and risk management are not fully reliable.
Accident and incident reports lacked detail about the actions taken afterwards... Safeguarding concerns were reported as required to the local authority but not to the Care Quality Commission (CQC)... Risk assessments were not conducted for individuals using emollient creams in relation to potential fire hazards.
Recruitment forms do not fully check candidate suitability and there is no set way to decide staffing numbers, even though levels are adequate now.
Improvements were required to some parts of the recruitment process... application and interview form to ensure full information was requested... not a systematic approach to determining the number of staff required to meet people’s needs.
AI Generated
Last inspected: November 2019
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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