Last updated: 9 February 2026
"Innovative activities and strong training, but no registered manager and safety issues with medicines and falls hold it back."
Medicines not always given as prescribed despite MARs signed; medicines found on floor not reported timely; 21 falls in 3 weeks with no trend analysis (2021).
Staff spoke positively about management and felt supported; 'Teamwork is good, the team leaders and managers are very helpful' (2021).
There were sufficient numbers of staff deployed to meet people's needs (2021 report).
Per 2019 comprehensive inspection: Staff up to date with relevant training including dementia, safeguarding, specialist areas like managing falls, skin integrity; regular supervision and appraisals.
The service did not have a manager registered with the CQC, however the current manager had applied to register and this was being assessed; relatives unaware of manager, oversight gaps in medicines and falls.
Per 2019: Activities coordinator, named innovations like Railway, sensory room, Eden Alternative philosophy, intergenerational classes, community partnerships, awards for dementia activities improvements.
No permanent manager in post, and leaders missing issues like medication errors and falls analysis.
The service did not have a manager registered with the Care Quality Commission... improvement was needed in relation to medicines, falls management and the way the service was being managed.
Medication errors where people did not get their meds on time, and incidents not reported or escalated properly.
We found evidence people's medicines were not always given as prescribed even though Medicines Administration Records (MARs) showed they were... both incidents had not been recorded as medicines incidents.
Lots of falls but no checks to spot patterns or reduce them.
falls records... showed there were twenty-one falls... There was no further analysis undertaken to identify any trends and to reduce the number of falls at the service.
AI Generated
Last inspected: August 2021
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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