Last updated: 10 February 2026
"Some group activities and staff sometimes feeling supported, but shortages of skilled carers, weak governance and training gaps hold it back."
The service was in breach of 2 legal regulations in relation to safe and effective staffing and care and treatment including safe management of risks, safe management of medicines and infection control.
Feedback from staff about the management was mixed, some reflected that they felt supported, however staff also reflected that they could raise concerns but that actions were not taken in response.
The provider did not make sure there were enough qualified, skilled and experienced staff... Comments included, “No, not during the day. They need 2 or 3 more.”
The provider had not always ensured that staff received all training relevant to their role, this included ensuring that staff were suitably trained and skilled to support people with specific conditions such as epilepsy, diabetes and catheter care.
The providers governance processes were not robust, with audits and monitoring not identifying any of the issues we noted during the assessment.
We observed a group activity in the lounge... a game of bingo had been arranged... However, we did not observe people who spent time in bed or in their rooms being supported to engage in meaningful activities... less than 10 hours each of social activity over this 79 day period.
Not enough carers on shifts, so staff are always rushing and people wait too long for help.
“No, not during the day. They need 2 or 3 more. They’re [staff] never sitting still, they’re always dealing with things”
Gaps in training for conditions like epilepsy, diabetes, dementia, and supervisions not done on time.
Out of 25 staff who deliver care, there were 20 staff who did not have mental capacity training... out of 29 staff... 25 staff who did not have training in responding to changes in people’s behaviour
Risk plans missing for things like seizures or pressure sores, and medication not always handled right.
one person had a diagnosis of epilepsy, however there was no care plan or risk assessment in place... repositioning was taking place between 2.5 hours and up to 7.5 hours... medicines given covertly... ‘Do not use milk or carbonated water'.
AI Generated
Last inspected: September 2025
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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