Last updated: 10 February 2026
"Staff feel valued and supported with good training, but staffing shortages, poor safety and weak management hold it back."
The provider was in breach of the legal regulations relating to safe care and treatment, premises and equipment... Fire evacuation procedures were not robust... Effective arrangements were not in place to monitor the safety of the premises and equipment to keep people safe.
Staff felt valued and treated in a way which supported their well being... They felt listened to and the provider was responsive to their suggestions, views or concerns. A staff member told us, '[Registered manager and care manager] are friendly, supportive, and honest.'
We could not be assured that there were sufficient staff available to support people... Staffing arrangements had not considered people’s needs. A dependency assessment had not been undertaken... The provider was in breach of the legal regulations... in relation to... staffing.
Staff received training appropriate and relevant to their role and their competency to manage and administer medicines was assessed. Training was refreshed at regular intervals to maintain knowledge and skills in line with best practice.
The provider did not have clear responsibilities, roles, systems of accountability or good governance in place. They did not always act on the best information about risk, performance and outcomes... The provider was in breach of the legal regulation in relation to good governance at the service.
We saw some daily records which identified what people had been engaged in doing around the service, and if people had gone out shopping, to the cinema or somewhere to eat. Some people pursued their hobbies such as football, having a beer and playing games.
Not enough staff on shifts, just one carer for three people all day and night, so no one to supervise risks like kitchen access or join outings.
staffing arrangements being 1 staff member on a day shift from 8am to 8pm and 1 staff member on the night shift from 8pm to 8am... with only 1 staff member on duty, people could be at potential risk if not supervised... no evidence provided... of staff being on duty at these times to provide the support people needed.
Unsafe fire drills and evacuation plans, no night drills done and missing details like how to help people with mobility get out quickly.
Fire evacuation procedures were not robust. We saw evidence that two fire drills had been undertaken in the daytime and did not identify clear details of the evacuation procedure... The provider had not undertaken a nighttime fire drill... PEEP’s lacked information about... guidance for staff to support a person with their mobility care needs.
No proper oversight from managers, so big risks like fire safety and staffing shortages went unnoticed for too long.
Governance systems needed improving to monitor the quality and safety of the service... The provider did not have effective management systems in place and failed to identify the concerns highlighted within this assessment... provider was in breach of the legal regulation in relation to good governance.
AI Generated
Last inspected: October 2025
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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