Last updated: 10 February 2026
"Staff feel well supported with high morale and diverse activities, but medication safety lapses and inconsistent management hold it back."
The service was in breach of the legal regulation in relation to people’s safe care and treatment... staff did not adhere to safe medication practice such as completing controlled drugs stock checks which put people at risk.
Morale is very high because we always get the support we want and need. We get regular breaks and feel supported. Wellbeing is looked after. [The registered Manager] is very concerned about staff and making sure we are fine so we can care for [people].
Staff told us that they felt there were enough staff to meet people’s needs, however some people and family members told us at times it felt like there were not enough staff on duty... no housekeeping or laundry staff scheduled to work on Sundays.
after some incidents had occurred, managers identified a need for staff training on positive behaviour support. However, this training need was repeatedly identified after several incidents and had still not occurred at the time of inspection.
Governance systems were not always effective. Audit schedules were inconsistent, and the data gathered in audits varied from month to month. Where audits were missing, actions from the registered manager had not consistently been taken to mitigate the risks.
the service had a busy and diverse activity schedule and we observed people being supported to walk in the gardens... activities co-ordinator had created a very person-centred scrapbook.
Medication handling has big problems like missing stock checks on controlled drugs and no proper audits, so errors might not get spotted and could harm residents.
staff did not adhere to safe medication practice such as completing controlled drugs stock checks... The provider did not have a robust process for auditing medication management to identify and mitigate risks
Managers do not always learn from repeated incidents or provide needed training like on positive behaviour support.
learning from incidents was not always evident and there were instances of repeated similar incidents... this training need was repeatedly identified after several incidents and had still not occurred
Staffing is adequate most times but feels short at weekends with no housekeeping cover and no monitoring of call bell response times.
no housekeeping or laundry staff scheduled to work on Sundays, creating a gap... The provider did not have a process of auditing staff response times to call bells
AI Generated
Last inspected: June 2024
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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