Last updated: 9 February 2026
"Enough staff and specialist eating disorder programmes, but absent management, training gaps and frequent medicine errors hold it back."
Over a period of two months we identified records showing 19 medicine errors... Not all risks to people had been fully explored and therefore there was a lack of clear guidance for staff.
Some staff told us they did not feel supported in their role by the management team... they did not feel comfortable to approach the clinical lead... The service had not conducted a staff meeting since opening.
There were sufficient staff on duty to meet the needs of people living in the service. The service did not use agency staff but utilised staff from their other two services.
Some staff we spoke with did not have a full understanding of the risks relating to eating disorders... Most staff we spoke with did not understand autism; staff told us they did not feel the online training they received had been sufficient.
There was little evidence of the registered manager being fully involved and having clear oversight of the service; staff told us they had never met the registered manager in person.
The service specialised in supporting people with eating disorders. Specific programmes had been designed... In house, the service was able to provide dietitian, occupational therapist and art and drama therapist support.
The manager splits time across other homes and is rarely there, so staff feel unsupported and unable to speak up easily.
A staff member told us they had never met the registered manager in person and therefore did not feel able to approach them.
Staff training has big gaps on autism and eating disorder risks, and supervisions do not happen regularly.
Most staff we spoke with did not understand autism and how this might impact autistic people being supported in the service... While records showed supervisions being planned, some staff told us they had not received regular supervision.
Frequent medication errors and missing risk guides mean daily safety work is unreliable.
Over a period of two months we identified records showing 19 medicine errors... Risks to people had not been fully assessed and clear guidance for staff had not been implemented.
AI Generated
Last inspected: December 2022
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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