Last updated: 9 February 2026
"Passionate leadership, family-like team culture, and engaging activities, but poor risk management and outdated staff competencies need improvement."
Risks to people were not consistently identified, mitigated, and reviewed... no management plan in place to mitigate those risks... care plans and risk assessments were not updated to reflect changes.
Staff felt they worked well as a team, and they supported each other well on shifts. Staff told us that working in the service felt like being part of a family, and they all worked as one.
Whilst records and feedback from people and staff indicated staffing levels were suitable, some staff felt staffing levels were not sufficient to enable them to provide the high-quality care they aspired to, because of the volume of administration tasks.
Staff involved in medicine administration were required... to have their competencies assessed... every 6 months. Whilst... audits had identified staff competencies... were not up to date, we found despite this a number of staff were administering medicines without an up-to-date medicine competency assessment completed.
The registered manager was actively involved in the running of the service. They were passionate in providing person centred care and had positive relationships with people, relatives, and staff.
The service had established community links and people had access to regular, varied, and engaging activities... boat trips, pub lunches, theatre dementia screenings, garden and craft mornings and Tuesday tunes at the library... arts and crafts, pampering sessions... pet a dog and alpacas.
Risk plans for falls, seizures, diabetes, and skin creams are often missing or outdated, so staff have to manage dangers without clear guidance.
Records showed risks to people were not mitigated... no management plan in place to mitigate those risks... care plan, and risk assessments were not updated to reflect changes in the person's health and mobility.
Staff skills checks for giving medicines, moving people, and personal care are overdue or missing, especially for new staff.
None of the new staff had completed the personal care competency assessments... The last moving and handling competency assessments were completed in December 2022... no overview of who had their competencies assessed.
Hiring checks like references are missing for some staff and agency workers, and shifts are filled with some agency cover amid complaints of being stretched.
In 3 out of the 5 staff recruitment files viewed, we found references were not on file... The service used agency staff to cover vacancies... the agency proforma provided did not indicate that references were obtained.
AI Generated
Last inspected: May 2023
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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