Last updated: 10 February 2026
"Staff feel supported by the new manager, but no registered manager in place, reliance on agency staff without dementia training, and training gaps undermine the workplace."
The service was in breach of legal regulation in relation to people’s safe care and treatment, the ways people’s medicines were managed safely, people not being protected the risk of abuse and neglect, safe staffing, the unsafe environment
Staff fed back they felt supported by the new manager. Of the management in the service 1 person told us, 'The staff here are generally good- But the manager just comes around and shouts. We call her the Sargeant Major'
On the majority of day and night shifts the service used regular agency staff however, according to their agency profiles, none of the staff had received dementia training. This was particularly concerning given the majority of people living at the service were living with dementia
Supervisions were not effective in driving improvements. We saw from 1 supervision the manager had undertaken with a member of housekeeping staff, that Control of Substances Hazardous to Health (COSHH) training was required for them. However, when we checked the training matrix this had not been provided
There had not been a registered manager at the service since July 2024 which is a legal requirement. We were not assured about the capability of the manager or that they had knowledge of people’s complex needs, or oversight of the service
No activities, engagement programmes, creative approaches, or distinctive practices mentioned; report focuses solely on routine personal care delivery failures
No permanent manager, and the current one lacks knowledge of residents needs and proper oversight.
There had not been a registered manager at the service since July 2024 which is a legal requirement. We were not assured about the capability of the manager or that they had knowledge of people’s complex needs, or oversight of the service
Most shifts rely on agency staff without dementia training, despite most residents having dementia.
On the majority of day and night shifts the service used regular agency staff however, according to their agency profiles, none of the staff had received dementia training. This was particularly concerning given the majority of people living at the service were living with dementia
Big gaps in staff training, like missing mandatory courses recommended in supervisions.
Supervisions were not effective in driving improvements. We saw from 1 supervision the manager had undertaken with a member of housekeeping staff, that Control of Substances Hazardous to Health (COSHH) training was required for them. However, when we checked the training matrix this had not been provided
AI Generated
Last inspected: July 2025
Management Quality
Well-led: Inadequate
Direct feedback from current and former employees

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