Last updated: 10 February 2026
"Staff feel able to speak up with managers and enjoy good activities and outings, but unsafe medicines management and missed quality checks hold it back."
We found medicines were not always managed safely. For example, a total of 13 people who used the service had not received their medicines due to lack of stock... some items had been out of stock for several days, one person had not received their ear treatment for eight days. Two people's DoLS had expired without renewal for two months.
Staff told us they felt they could speak up with management if they need to. Meetings were held with staff to identify any issues or concerns. All staff we spoke with told us they could always approach the management to discuss any concerns or worries they had.
Staff gave us mixed views about the level of staffing to meet people's needs. Some staff said staffing was an issue whilst others reported staffing was not a problem. 'I have to direct agency staff when they have never been here before, it puts us under pressure.'
Staff reported that they did not always receive regular supervisions. One member of staff told us they had a supervision 'sometime last year'. Supervisions were not always carried out in line with the provider's policy of monthly or minimum six per year.
Audits completed at the service did not capture all of the issues we identified as part of our inspection, including medicines, supervisions and DoLS.
The service received visits from the local churches. A local play group also visited the home every two weeks with their parents... joined people in activities such as painting, colouring and jigsaws. The service took people out to the local garden centre, farm, and into Aylesbury town for shopping in addition to visiting the local pub for lunch.
People missed medicines for pain, depression, and dementia because the home ran out of stock for days.
a total of 13 people who used the service had not received their medicines due to lack of stock. The medicines were for various conditions including treatment for depression, pain management and managing symptoms of dementia... some items had been out of stock for several days
Staff go without regular one-on-one meetings with managers, some have not had one since last year.
Staff reported that they did not always receive regular supervisions. One member of staff told us they had a supervision "sometime last year"."
The manager's quality checks missed problems like medicine shortages and out-of-date legal papers for restricting freedom.
Audits were undertaken by the provider. However, the audits had not identified the issues we found in relation to medicines, supervisions and DoLS applications.
AI Generated
Last inspected: July 2019
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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