Last updated: 10 February 2026
"Varied activities and trips out with enough staff on shifts, but major gaps in training and safety like unlearned falls hold it back."
People’s safety was not consistently considered. There were no records of lessons learned when people experienced falls, the numbers of falls at the service had not decreased in six months. Risk assessments relating to falls were incomplete and lacked advice for staff.
Staff told us that over the past six months they had not been listened to by managers all of the time and did not feel as supported as they needed.
There was some dependence on agency staff to cover unexpected absences or when short notice, one to one support was needed for people. Generally, there were enough staff on each shift to support people safely.
There had been no staff refresher training in dementia, safeguarding or manual handling and no training at all in end of life support.
The new registered manager had only been in post a few days and acknowledged these shortfalls and planned to put things right and to prioritise people’s safety. However, this would take time to embed.
People had a variety of activities they could engage with including regular trips out in the service minibus and many group activities in the communal areas of the service.
No refresher training on dementia, safeguarding, or safely moving residents, and no end of life training at all.
There had been no staff refresher training in dementia, safeguarding or manual handling and no training at all in end of life support.
Big safety gaps like no learning from falls, incomplete risk assessments, and unrecorded medication errors.
There were no records of lessons learned when people experienced falls... Medicine errors had not been recorded and not all PRN (as required) medicines had protocols in place.
New manager just started a few days ago, with no recent staff supervisions or audits for six months.
Staff had not had supervision meetings enabling them to raise concerns and issues. ... There had been no effective auditing processes in place for the past six months.
AI Generated
Last inspected: December 2022
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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