Last updated: 9 February 2026
"Enough staff to meet needs and varied activities, but unsafe medicines management and ineffective audits missed key concerns."
Medicines were not always managed safely and according to best practice. We saw some people had not received their medicines due to staff either not being able to locate the medicine or not following instructions by the prescriber. In addition, we saw missing signatures on some medicine charts.
Staff had regular opportunities to share their views on the way the service was run in team meetings and supervisions. In addition, staff told us the registered manager had an open-door policy and they could always speak with them at any time.
From our observations during our inspection we saw staff were able to spend time with people without rushing. Call bells were answered in good time... We concluded there were enough staff to ensure people's needs were met.
The service ensured staff received updates in their training, such as moving and handling and safeguarding and had received regular supervisions and appraisals.
Audits completed by the registered manager were ineffective; they had not identified the concerns we found during the inspection in relation to medicine management, mattress settings, body repositioning records and risk assessments.
The activities coordinator provided a varied programme of events and entertainment throughout the week. These included, quizzes, recitals, exercise classes, French lessons and productions such as children's shows. In addition, trips out were organised to local places of interest.
Medication errors like missed doses, misread instructions, and poor storage put people at risk.
Medicines were not always managed safely... some people had not received their medicines... missing signatures on some medicine charts (MARs)
Managers checks missed safety problems with medications, risks, and care records.
Systems of governance and oversight were not sufficiently robust to have identified the issues we found in relation to managing risks and the management of medicines.
Risk plans are often missing or not followed, like for choking, skin damage, or self-medication.
Risk management was not always comprehensive and up to date. People who had been identified at risk did not always have documentation in place to guide staff.
AI Generated
Last inspected: October 2019
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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