Last updated: 10 February 2026
"Staff feel valued and supported with enough staff and varied activities, but delayed incident investigations and safety training gaps hold it back."
Whilst processes were in place to investigate incidents, these were not consistently applied with delays between incidents occurring and investigations being completed, and safeguarding concerns with unclear DoLS understanding.
Staff told us 'The manager does care for us, not just as staff but as people as well' and 'Management are very open to listening, very good flexibility with work'.
Staff and relatives told us there were enough staff on shift. The provider undertook safe recruitment processes and pre-employment checks.
The provider ensured staff received training relevant to their role, but not all staff preparing foods had undertaken dysphagia training and the registered manager’s training and competency assessment had expired.
The registered manager oversaw staff performance, undertook supervisions and provided support where needed, but several concerns had not been detected through internal processes including gaps in consent and MCA compliance.
People living at the service attended various activities including slimming clubs, bereavement groups, church, beauticians, local coffee shops, cinema and sensory groups with a service vehicle to support attendance.
Accidents and mistakes aren't always investigated quickly or fully to learn from them and stop repeats, like medication errors taking over 30 days.
investigation completion of two medication-related incidents report on the 14th and 29th March exceeded 30 days in line with the providers policy without rationale for exceeding this timeframe.
Safety risks like choking aren't handled right because not all staff know how to prepare food to the correct texture.
The provider did not manage choking risks safely. Records did not clearly demonstrate people were given food in line with the modified texture... Not all staff preparing foods had undertaken dysphagia training.
Checks by leaders miss key problems like wrong decisions on people's freedom without proper mental capacity assessments.
several concerns identified during the inspection had not been detected through internal processes. These included gaps in consent documentation, incomplete records relating to risk, and non-compliance with the Mental Capacity Act (MCA).
AI Generated
Last inspected: November 2025
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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