Last updated: 10 February 2026
"Staff feel supported with some activities for residents, but unsafe long shifts, poor leadership and lack of training hold it back."
Safeguarding Score:1 Whilst a family member felt their loved one was safe in the home, we found people were not protected from the risk of abuse... leaders and staff had not investigated this or reported it the safeguarding team.
Workforce wellbeing and enablement Score:1 Whilst staff told us they felt supported, they were working long hours and multiple shifts with no formal break... This could lead to decreased quality of care for people and higher risk of errors.
Safe and effective staffing Score:1 Staff working hours were unsafe. The provider told us, and we confirmed from rotas, staff were doing 12 hours shifts with no breaks 3 days in a row and that member of staff was also the sleep-in member of staff each night of that shift.
The provider failed to ensure staff were suitably trained and supervised to carry out their role. Where people had epilepsy, acquired brain injury and mental health diagnosis, we saw from the training matrix that staff, including the leaders, had not been trained in these areas.
Capable, compassionate and inclusive leaders Score:1 The provider did not have inclusive leaders at all levels who understood the context in which they delivered care... Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.
People and relatives felt there were insufficient activities being provided. Relatives also fed back that people were not always supported to develop friendships... We did see evidence of a person enjoying activities when in the home including art and playing word games.
Staff have to work 12-hour shifts three days straight with no breaks and do night checks while sleeping over, leaving them exhausted and at risk of mistakes.
staff were doing 12 hours shifts with no breaks 3 days in a row and that member of staff was also the sleep-in member of staff each night of that shift. Staff also told us they were required to wake twice during the night to check on people. There were also no formal breaks provided to staff.
No training for staff on epilepsy, brain injuries, or mental health even though residents have these needs.
Where people had epilepsy, acquired brain injury and mental health diagnosis, we saw from the training matrix that staff, including the leaders, had not been trained in these areas.
Leaders lack skills and oversight, missing big problems like unsafe practices and poor care records.
The provider told us of their oversight, “When you are in it, you can’t see it.” There were no audits of care notes, care plans and staff interactions with people.
AI Generated
Last inspected: May 2025
Management Quality
Well-led: Inadequate
Direct feedback from current and former employees

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