Last updated: 10 February 2026
"Staff receive thorough training in a caring, supportive culture with engaging activities, but leaders' quality checks miss medicine record gaps and paperwork issues."
Medicines Administration Records (MAR) we reviewed showed that people received their medicines as prescribed. However, when people were prescribed creams and other topical preparations, it was not always clearly recorded where these were applied.
One staff member said, "Staff are caring and work together as a team putting people first." Relatives and staff told us they found the management team to be visible in the service and supportive.
There were enough appropriately skilled staff to support people safely. During the inspection we saw staff deployed appropriately throughout the service.
Staff completed a comprehensive induction which included mandatory and specialised training, shadowing of experienced staff, orientation to the service and familiarisation of people and their care needs.
The provider had a quality assurance system in place. However, this had not identified the gaps we found during our inspection. For example, medicine audits had not identified the shortfalls within the PRN protocols or recording of use of topical creams.
The activity co-ordinator was passionate about their role and motivated people to access activities of their choice. People were supported by the staff team to access the community and pursue personal interests.
Leaders quality checks miss problems like gaps in medicine records and legal paperwork not sent on time.
A review conducted by the CQC prior to this inspection, identified the provider had not submitted required notifications regarding the renewal of DoLS authorisations... medicine audits had not identified the shortfalls within the PRN protocols or recording of use of topical creams.
Staff numbers are enough but they use agency workers at times.
We looked at four staff members files and one agency staff file in relation to recruitment.
Some gaps in medicine records and care notes like where creams are applied or outdated details, even though fixed quickly.
when people were prescribed creams and other topical preparations, it was not always clearly recorded where these were applied... for one person there was a discrepancy recorded in the care records relating to dietary requirements.
AI Generated
Last inspected: October 2022
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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