Last updated: 9 February 2026
"Good training and inductions for new and established staff, but unstable leadership, heavy agency use and a punitive culture undermine it."
The service was in breach of legal regulation in relation to people’s safe care and treatment, the safe management of people’s medicines, safe staffing and governance relating to safety.
The culture at the service was not always viewed as a supportive one, with some staff describing it as punitive. Multiple staff told us they felt unable to do this due to what they perceived as a punitive culture.
We found there was a reliance on agency staff. These staff did not always receive an appropriate induction and support for staff in general required improvement. Some care staff we spoke with told us there were not enough staff.
New staff received a comprehensive induction and were positive about this. Established staff received training including refresher training in core skills.
The relatively new in post manager told us they did not feel supported and terminated their employment during the assessment process. Key management positions were vacant at the time of our assessment.
Activities were not varied, and some people were unhappy about the provision. We saw no activities taking place for people living with dementia during our onsite visits.
No stable manager in place, lots of changes and key roles empty, so leadership feels unstable and unsupported.
Since our last assessment in October 2020, there have been 4 registered managers and additional managers and temporary managers in post in between. Key management positions were vacant.
Heavy use of agency staff who don't know residents, and not enough permanent staff so shifts are uncovered and everyone feels overwhelmed.
Staffing levels did not ensure people were kept safe and a high level of agency cover meant staff were not always able to meet people’s needs. The permanent staff are overwhelmed.
Staff say the culture feels punitive and they hesitate to raise concerns or get regular supervision.
Some staff, including senior staff, spoke of a punitive rather than an inclusive and empowering culture. Supervision was not always a two-way process and was not as regular as they would have liked.
AI Generated
Last inspected: March 2021
Management Quality
Well-led: Inadequate
Direct feedback from current and former employees

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