Last updated: 10 February 2026
"Regular supervision, staff meetings and consistent staffing, but poor governance, recruitment checks and basic activities hold it back."
We found where people were prescribed medicines when required (PRN), they did not always have a PRN protocol in place. The registered manager had been raising safeguarding alerts with the local authority however, there had been occasions whereby safeguarding notifications had not been sent to CQC as required.
Staff received regular supervision to discuss their support needs and any practice issues. Staff meetings were held regularly. We reviewed minutes and saw they included updates about people who used the service as well as reminders about training and examples of lessons learnt.
There were enough staff at the service to support people. The registered manager told us they had consistent staffing levels and did not need to use agency staff. The registered manager had not completed the appropriate checks to ensure that staff were recruited safely into the service. This demonstrated a breach of Regulation 19 [Fit and proper persons employed].
Staff received regular supervision to discuss their support needs and any practice issues. There were also daily staff handovers and regular staff meetings. Staff told us, 'We use our supervisions to discuss people and their wellbeing, the running of the service and how staff are progressing. I find the supervisions really valuable.'
Systems and processes to monitor, audit and improve the overall quality of the service were not robust enough. This was a breach of Regulation 17 [Good governance] of the Health and Social Care Act 2008 (Regulated activities) Regulations 2014.
People were engaged in various activities throughout the day, either independently or with members of staff. People went out for walks during the day and attended appointments. During our visit, people were using the service's minibus to go out for their activity. We also saw people being taken out for swimming later during the day.
Recruitment checks are often missing or done late, so new staff might start working alone without full safety vetting.
Relevant recruitment checks were not always completed before staff started work. It was unclear from the start dates in staff recruitment files if staff worked independently prior to references being verified. For example, some staff had references verified a month after their start date.
Bosses do not check or audit things well enough to spot and fix problems.
The quality assurance and governance arrangements in place were not always effective in identifying shortfalls in the service. Audits were ineffective and lacked detail. We found these to be mostly tick box audits, without action plans attached or with timescales for completion or staff identified responsible for the outcomes.
No proper activities programme or coordinator, so days are mostly routine care with basic outings like walks and swimming.
People were engaged in various activities throughout the day, either independently or with members of staff. People went out for walks during the day and attended appointments. During our visit, people were using the service's minibus to go out for their activity. We also saw people being taken out for swimming later during the day.
AI Generated
Last inspected: November 2023
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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