Last updated: 9 February 2026
"A good range of activities and personalised programmes, but low staffing especially at night, poor safety and missing key training hold it back."
People were not always fully protected and kept safe. Risks were not consistently recognised or managed in a proactive way to ensure people’s safety. Medicines were not always managed safely.
One staff member told us, “The staff are frightened to talk.” Another staff member told us, “I don’t feel I want to speak out anymore as I feel like nothing will change and whatever I say will act against me.”
Although the provider used a dependency tool and confirmed there were enough staff in place to support people, we received feedback from people and staff that there was not enough staff to support people and respond to their immediate needs. One staff member told us, “At nighttime, there is 1 nurse and 1 carer. I don’t know how they are surviving; it is horrible.”
We reviewed the staff training matrix and found there was a lack of evidence of specific training and competency completed for specific topics including catheter care, administration of rectal diazepam and percutaneous endoscopic gastrostomy (PEG).
Staff told us they did not always feel supported by the leadership team. Relatives also told us they did not always feel management was visible and worked well with staff.
A range of activities was available for people, and some personalised activities they requested were implemented. The activities team told us about the range of individual activities implemented to support people. We observed some group and individual activities taking place during our visit.
Recruitment checks were incomplete with gaps in work history not verified before staff started, and staffing feels too low especially nights with just one nurse and one carer.
The registered manager did not operate effective and robust recruitment procedures to ensure they employed suitable staff. We found discrepancies with gathering information of full employment history and unexplained gaps... At nighttime, there is 1 nurse and 1 carer. I don’t know how they are surviving; it is horrible.”
Key training is missing for things like catheter care, feeding tubes, and epilepsy support, and inductions feel weak.
We reviewed the staff training matrix and found there was a lack of evidence of specific training and competency completed for specific topics including catheter care, administration of rectal diazepam and percutaneous endoscopic gastrostomy (PEG)... Some staff members told us they did not feel the induction was robust.”
Safety risks like poor medicines handling, covert meds without proper checks, and unmanaged dangers such as epilepsy or fire hazards from creams are not handled well.
Medicines were not always managed safely... There were 4 people receiving medicines covertly... no personalised care plans... High risk conditions were not always captured in people’s care plans... risks relating to paraffin-based creams were monitored and managed effectively.”
AI Generated
Last inspected: March 2019
Management Quality
Well-led: Outstanding
Direct feedback from current and former employees

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