Last updated: 9 February 2026
"Good training and engaging activities, but staffing shortages, safety risks and weak management oversight put residents at risk."
We identified 2 breaches of regulation relating to people receiving safe care and treatment... Concerns were identified in relation to people’s assessed needs and risks relating to catheter care, fluid intake and repositioning were not effectively managed or monitored.
Poor morale due to staffing levels, the morning shifts are the worst shifts. It is stressful getting people up... Staff don't always want to speak up because they are scared and don't feel they can trust management.
On 3 March 2025 there were not enough staff to meet people’s needs. We observed people’s safety was put at risk, for example, people living with dementia and at high risk of falling were in a lounge unsupervised by staff.
Staff training was up to date and they understood their responsibility to protect people from abuse. Staff received appropriate training and updates to meet people’s specific needs.
Management oversight, governance systems and audits had not been used effectively to assess, monitor and improve the quality and safety of the service.
The activities staff member told us about the group and individual activities and shared the weekly programme... company car... coach trip to the seaside... dementia club, Thursdays the Dementia sing out, we alternate with the school.
Not enough staff on shifts, especially mornings and weekends, with lots of agency workers and staff under pressure.
A person told us,“They are under pressure... there’s a lot of agency staff.” Staff: “Poor morale due to staffing levels, the morning shifts are the worst shifts.”
Risks to residents like poor repositioning, fluid tracking, catheter care, and unsafe medication storage not managed well.
district nurse requested a person needed to be repositioned 3 hourly but the care logs showed staff repositioned the person 5 hourly... people had identified fluid intake targets but the intake targets were not always met... treatment room door was unlocked and medicine stored in the unlocked fridges were accessible.
Managers not overseeing things properly, audits unreliable, and staff scared to speak up.
Provider oversight and governance system was not used effectively... most staff were not confident to speak up... Staff don't always want to speak up because they are scared and don't feel they can trust management.
AI Generated
Last inspected: May 2025
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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