Last updated: 9 February 2026
"Staff feel supported in a positive culture with enough staff to meet needs, but safety risks from unreported incidents and managers slow to fix problems need attention."
We found 3 breaches of regulation relating to safe care and treatment, safeguarding and the management of the service... Incidents had not always been recognised and reported as safeguarding concerns... Potential risks to people’s health and welfare had not been consistently assessed.
Staff were positive about the support they were given by the management team and were confident to raise concerns... Staff told us, there was a positive culture within the service. They described how the management was visible around the service and understood people's needs.
There were enough staff to meet people’s needs... the service has dramatically reduced its use of agency staff... don't have any vacancies at time of assessment but do know that some hours will need recruiting to soon due to staff circumstances.
Staff had not received regular supervision and had not consistently received training to meet people’s needs... Some staff had not had a supervision during 2024, and other staff had only had one this year. Staff had not always had training to meet the needs of people, for example, staff had not received catheter care training.
The provider had systems in place to monitor the quality of the service. However, the systems had not been used effectively by the management team. When shortfalls were identified, these were added to an action plan. There had been little action taken to rectify the shortfalls and some actions had not been completed though they had been identified over 6 months previously.
Relatives told us staff had time to spend with people doing what they wanted. Their comments included... staff take the time to do their hair and put nail polish on them.”
Managers spotted problems in audits but did not fix them quickly, even after months on action plans.
The management team had completed audits, issues had been identified but these had not been acted on... not all actions had been completed, for example the fire drill and sending out quality assurance surveys had not been completed after 8 months.
Staff missed key training like catheter care and did not get regular supervisions to improve their skills.
Staff had not received regular supervision and had not consistently received training to meet people’s needs... staff had not received catheter care training.
Incidents were not always analysed for patterns or reported as safeguarding concerns, leaving people at risk.
Accidents and incidents had not always been analysed for patterns and trends. Action had not been taken quickly to reduce the risk of them happening again... Some incidents had not been recognised as potential safeguarding concerns and had not been reported to the local authority as required.
AI Generated
Last inspected: November 2024
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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