Last updated: 10 February 2026
"Staff feel supported with good teamwork and training, but staffing shortages delay call bells and unexplained injuries go uninvestigated."
People were at risk of potential abuse. When a person had an unexplained injury, the registered manager had not always completed an investigation to identify the potential cause and to put mitigating factors in to reduce the risk of reoccurrence.
Staff felt supported within their roles and felt they worked well as a team.
The call bell audit identified on numerous occasions staff were unable to respond to people due to 'all staff attending to another person.' For example, the weekly audit evidenced between 19 May 2023 and 25 May 2023, there were 8 occasions when staff took longer than 10 minutes to respond to people due to not enough staff being on shift.
People were supported by staff who had been safely recruited and who had received sufficient training.
Systems and processes were not always effective in assessing, monitoring, and improving the quality of the service. Concerns found on inspection had not been identified or rectified.
Not enough staff on some shifts, so call bells take over 10 minutes to answer sometimes and people wait for washes or showers.
the weekly audit evidenced between 19 May 2023 and 25 May 2023, there were 8 occasions when staff took longer than 10 minutes to respond to people due to not enough staff being on shift.
Unexplained injuries on residents not always investigated, leaving risks of harm unaddressed.
When a person had an unexplained injury, the registered manager had not always completed an investigation to identify the potential cause and to put mitigating factors in to reduce the risk of reoccurrence.
Weak oversight misses problems like incomplete risk assessments and poor records until inspection.
Systems and processes were not always effective in assessing, monitoring, and improving the quality of the service. Concerns found on inspection had not been identified or rectified.
AI Generated
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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