Last updated: 9 February 2026
"Staff enjoy a supportive culture with regular training and varied activities, but low evening staffing and incomplete medicines records are major concerns."
Medicines management did not consistently follow best practice with missing signatures, no PRN reasons and unassessed competency; care plans and risk assessments not consistently updated; DoLS required but not applied.
Staff were positive about working at the service; a staff member said 'Staff morale most of the time is good, I enjoy working here, the management team are all very supportive'.
The staff rota for October 2022 showed examples of 5 occasions when 2 staff were allocated to work an evening shift when 3 were required per dependency tool, plus 5 care staff vacancies.
Per 2020 comprehensive inspection: The provider maintained a comprehensive training programme including Care Certificate for new staff and regular training; staff said 'We have regular training. I learn something new every time'.
People spoke highly of the registered manager and provider's approach but systems and processes to assess, monitor and review quality and safety had some shortfalls including ineffective audits.
Per 2020 comprehensive inspection: Activities coordinator worked three afternoons weekly organising programme with variety including music to movement, quizzes, entertainers, outings to cinema and garden centre, art and knitting groups.
Staffing levels often too low especially on evenings so residents wait ages for help or have accidents waiting.
The staff rota for October 2022 showed examples of 5 occasions when 2 staff were allocated to work an evening shift. People raised concerns about staff deployment and having to wait for assistance... pressed the bell 3 times... had a couple of accidents.
Medication records incomplete like missing signatures and reasons for as-needed doses plus risk plans not kept up to date.
Handwritten entries on Medicine Administration Records (MAR) did not have a second staff signature... Medicines prescribed 'when required' did not record the reason... Care plans and risk assessments had not consistently been updated.
Weak oversight with audits and checks not spotting issues like low staffing and old records.
Governance audits and checks had not identified the concerns found during this inspection. Staff deployment had not been sufficiently assessed and monitored... Medicines audits and checks were not sufficiently robust.
AI Generated
Last inspected: December 2022
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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