Last updated: 10 February 2026
"Staff receive good training and feel supported by the manager, but major safety failures, staffing shortages and lack of meaningful activities hold it back."
The service was in breach of legal regulation in relation to people’s safe care and treatment, particularly in relation to accidents and incidents, infection control and medicines. They were also in breach of regulations in relation to... safeguarding service users from abuse.
Staff told us, “We work well together and the team is supportive of each other.” One staff member said, “The manager does support me. She encourages me to be involved in the care plans which is good development for me.” A second staff member told us, “The manager’s door is always open. I felt very supported.”
Management had not ensured there were sufficient staff on duty each day to enable people to go out with staff on an individual or impromptu basis. The provider allowed staff to work exceptionally long hours without a break meaning people were cared for by staff who may be tired and as a result may not provide high-quality care.
Staff told us they received good training, supervision and support from the registered manager and it was evident they knew people well. A staff member said, “The training is good. It’s mainly on DVD. We do the Care Certificate... we do competency assessments for medicines.”
Management had failed to recognise where safeguarding incidents had occurred and as such had not reported these appropriately to the relevant authorities. In addition, where accidents and incidents occurred, although action was taken at the time, learning from these was not embedded robustly to help reduce future incidents.
People’s lives were very insular with little evidence of them going out or attending activities that were meaningful to them and their goals or ambitions were not always pursued by staff. There was little evidence of staff supporting people to develop life skills to enable them to work towards living on their own.
Staffing levels too low for individual or spontaneous outings, and managers let staff work very long shifts without breaks leaving everyone tired.
There were 4 staff on duty each day to care for 13 people, one of whom required 1 to 1 staffing throughout the day and 2 to1 staffing when going out... the deputy manager worked 3 consecutive weeks Monday to Friday at the service (completing 53, 50 and 47 hours respectively) while also being on call for the full 7 days each week.
No real activities or skills training for residents, so your days would mostly be routine personal care and watching TV.
Throughout our first visit, people spent most of the day sat doing nothing. They were in the lounge watching television... upon review of the daily notes... we found only 3 people had been out on one occasion each. The other 3 people had spent their time indoors watching television or doing colouring.
Big safety problems like not reporting safeguarding concerns, dirty conditions that risk infection, and medication record errors.
Fourteen incidents were recorded, 7 of which met the threshold for safeguarding referrals. However, these had not been reported... On our first visit the service was not clean and there was an unpleasant smell... Records relating to medicines were not accurate... stock count... discrepancy.
AI Generated
Last inspected: September 2025
Management Quality
Well-led: Inadequate
Direct feedback from current and former employees

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