Last updated: 10 February 2026
"Staff feel well supported and valued with good training and enough staff, but poor accident investigations and ineffective management checks need improvement."
Where people had experienced incidents or accidents, we found there had not always been an investigation into how these had occurred. There was no accident or incident analysis carried out both at a person or service level.
Staff felt well supported in their role, felt able to raise any concerns and enjoyed their roles in supporting people who lived at the service. Staff felt respected, supported and valued by the registered manager.
The service had enough appropriately skilled staff to meet people's needs and keep them safe. Regular agency staff were being used to ensure safe staffing levels were in place.
Staff had received training on how to recognise and report abuse and they knew how to apply it. Staff had received training in medicine administration and had checks carried out on their competency.
Systems to monitor the service were not always effective. The registered manager completed a comprehensive audit covering many areas. This audit had not identified the areas needing improvement and in some places was incorrect. Breach of Regulation 17 (2)(a)(b).
Accidents and incidents are not reviewed properly or checked for patterns to prevent repeats.
There was no accident or incident analysis carried out both at a person or service level and opportunities to identify trends were lost.
Managers checks missed gaps in care plans, risk assessments, and medicine instructions.
Oversight of care plans had not identified that one person's information relating to care decisions was in another person's file. Monitoring checks had not identified where further detail was needed in protocols for as required medicines.
Regular agency workers cover staffing gaps while they recruit permanent staff.
Regular agency staff were being used to ensure safe staffing levels were in place. The registered manager was working hard to fill the staffing gaps with permanent staff through constant recruitment.
AI Generated
Last inspected: November 2022
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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