Last updated: 10 February 2026
"An open culture where staff feel valued, with enough staffing and varied activities, but major safety issues like poor accident reporting and unsafe medicines hold it back."
The service was in breach of legal regulation in relation to people’s safe care and treatment. Not all incidents and accidents had been reported or investigated. We found some shortfalls in medicines management processes.
Staff told us there was an open culture and they felt valued and respected by the management team. They spoke positively about the changes being implemented by the new manager and told us they felt valued and listened to.
People told us there were enough staff on duty and people’s relatives agreed with this. Staff we spoke with told us they felt there were enough of them on duty.
Training records did not always show that staff were trained and competent to carry out their roles. Although care staff had watched online videos in relation to skin and pressure care, knowledge around how to prevent skin damage was inconsistent.
Although leaders were responsive to our feedback, systems and processes in place had failed to identify and drive improvements across the service delivery. We were not assured the provider had effective governance systems in place.
There was a range of activities available for people to take part in if they chose to and the programme for these was on display in communal areas. This included coffee afternoons which were open to members of the public, entertainment, church visits, and visits from local schools, scouts, beavers and cubs.
Big safety issues like poor accident reporting, unlocked medicine storage, and weak risk management for skin damage and falls.
Not all incidents and accidents were reported. Medicines were not always managed safely. One room where medicines were stored was open and unlocked... care plans did not consistently provide clear guidance for staff on how to reduce the risks.
Training gaps in key areas like preventing skin damage and diabetes care, so staff knowledge is spotty.
Training records did not always show that staff were trained and competent to carry out their roles... records showed not all staff had been trained in diabetes.
Management oversight is weak and audits missed major problems with risks and medicines.
Although quality assurance processes were in place... systems and processes were ineffective and had not identified the shortfalls we found... Audits had not identified the issues we noted in relation to medicines management, the environment or risk management.
AI Generated
Last inspected: June 2024
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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