Last updated: 10 February 2026
"Staff feel supported with enough on duty and robust recruitment, but serious safety gaps around medicines and unreported bruising plus missing supervisions and training hold it back."
The service was in breach of legal regulation in relation to safe care and treatment, especially in relation to medicines; unexplained marks or bruising on people had not been reported to the local authority safeguarding team.
Staff told us, “I feel supported. They (management) are helpful. If there is anything not right we can talk to the manager to sort things” and “We support each other.”
We observed a sufficient number of staff on duty and observed no one having to wait for care; staff were recruited through a robust process.
Staff told us that supervisions and appraisals were not taking place; the chef had not received training on the International Dysphagia Diet Standardisation Initiative.
The registered manager had an open-door policy in which staff and people felt comfortable to raise concerns, but poor governance arrangements particularly around identifying and acting on shortfalls.
Group activities took place which included quizzes, bingo, quoits, aromatherapy and singing sessions; the activities co-ordinator was only in the service 3 days a week which restricted the time.
Medication errors and unreported bruising mean people aren't always kept safe properly.
We reviewed body maps that showed at least 3 instances of unexplained marks or bruising on people, yet these had not been reported to the local authority safeguarding team... records showed that during August it was only applied once on 11 occasions, twice on 4 days and not at all on 2 days.
Staff are missing supervisions and some key training like for swallowing problems and medication checks.
Staff told us that supervisions and appraisals were not taking place... the chef had not received training on the International Dysphagia Diet Standardisation Initiative... We haven’t done competencies yet.
Manager is behind on staff check-ins and not spotting problems like poor records or safety gaps.
I am behind on supervisions... no audits had been carried out so far this year... audits... had written ‘all standards met’. Yet, we had found poor records relating to people’s care plans and poor medicine management practices.
AI Generated
Last inspected: September 2025
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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