Last updated: 10 February 2026
"A positive culture supports staff well with engaging activities, but medicines not always safely managed and weak quality checks need fixing."
People's medicines were not always safely managed. Some 'when required' medicine protocols were not in place and some were lacking in detail... records did not demonstrate they were being rotated in line with manufacturer guidance.
There was a positive culture in the service and staff were supported in their roles to enable them to support the people living in the home.
There were enough staff on duty to support people safely. Although, some improvements were needed to the recruitment process in line with best practice and to ensure that it was robust.
Staff received relevant training and support, although some training had been effective. For example, MCA training needed improving to ensure people's mental capacity had been considered in relation to specific decisions.
The provider's quality assurance systems and processes were not always effective in identifying risks to people and in driving improvements in the service.
People were supported to take part in activities by the activities co-ordinator. We observed them explaining activities to people to support them to be involved.
Medication wasn't always handled safely, like missing protocols for as-needed creams and pain patches not rotated to right spots.
Some 'when required' medicine protocols were not in place and some were lacking in detail. For example, 1 person had a prescribed topical cream that was not on their medicine administration record and there was no 'when required' protocol in place... records did not demonstrate they were being rotated in line with manufacturer guidance.
Recruitment records had gaps such as missing job histories, unclear references, and unverified IDs on new staff.
We identified some gaps in recruitment files during our inspection visit. For example, 1 staff member's recruitment record contained gaps in their application form relating to their employment history and reasons for leaving previous jobs. Also, where copies of identification documents had been made, these had not been endorsed. Another staff member's reference information was not clear.
Training records don't clearly show what's done or overdue, and mental capacity training needs work to be useful.
The provider kept records of training on a matrix, however, it was not clear which training had been completed by staff and what still required completion... MCA training needed improving.
AI Generated
Last inspected: February 2024
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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