Last updated: 10 February 2026
"Staff feel supported with good teamwork and an approachable manager, but missing key training, staffing shortages, and poor safety and medicines management hold it back."
Risk management ineffective with unmitigated choking, epilepsy, flammable cream risks; unsafe medicines with no PRN protocols and inaccurate records, breaching regulation 12.
Staff felt supported with good teamwork and communication but poor practices observed like terms of endearment and 'good boy'.
The required staffing levels were not always provided which impacted on the level of supervision and support people received, including community access; high staff turnover noted by relatives.
No staff had MAPA training deemed mandatory, and staff lacked training in learning disability, anaphylaxis, and moving/handling had expired for some.
The registered manager was described as approachable and responsive by staff and relatives but lacked knowledge of MCA and provider audits failed to identify shortfalls in medicines and risks.
Relatives noted improved access to activities under new manager but staffing shortages limited community access and people had to wait for staff.
Staff are missing key training like handling aggression and some mandatory courses are out of date or expired.
no staff had Management of Actual and Potential Aggression (MAPA) training, which was deemed mandatory by the provider... moving and handling training had expired in September 2021
Not enough staff on some shifts so supervision is patchy and community outings get delayed.
The rotas viewed showed the staffing levels required were not always maintained with only four staff regularly provided on the day shift... impacted on people's community access
Medication records are messy with missing guidance for as-needed drugs and risks like choking or seizures not fully managed.
protocols were not in place for 'as required' PRN Lorazepam... Risks management was not effective in mitigating risks to people. Risks for one person around eating had not been identified
AI Generated
Last inspected: November 2022
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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