Last updated: 10 February 2026
"Good training and a positive culture where staff feel valued and supported, although high agency use earlier and no structured activities held it back."
Improvements were needed to record keeping in relation to lessons learned following accidents and incidents... Protocols were in place to guide staff when to administer medicines prescribed 'as needed' but two people's protocols did not provide enough guidance.
Staff felt respected, supported and valued by senior staff which supported a positive and improvement-driven culture. They felt able to raise concerns with managers without fear of what might happen as a result.
There had been a high use of agency staffing during the beginning of the year. However, staffing had improved, and no further agency staff usage was planned, following the inspection.
People were supported by staff who had received relevant and good quality training in evidence-based practice. This included training in... positive behaviour support, human rights and all restrictive interventions.
Management were visible in the service, approachable and demonstrated a genuine interest in what people, staff, family and other professionals had to say. Staff felt respected, supported and valued by senior staff.
People were supported to participate in their chosen social and leisure interests on a regular basis... There are no advance activities planned, we go by how people are feeling and what they want to do.
High staff turnover and agency use earlier this year put pressure on the remaining team and affected care consistency.
There had been a reliance on agency staff to achieve safe staffing levels at the beginning of the year. We received feedback from staff this increased the pressure on them as agency staff could not support the people that needed consistent and familiar support.
No structured activities programme or coordinator, so days are mostly about routine care plus ad-hoc outings when requested.
There are no advance activities planned, we go by how people are feeling and what they want to do. If [Name] wants to go for a drive, then they will make a gesture and we will go for a drive.
Record keeping gaps for incidents, debriefs and medicines mean lessons learned are not always fully documented.
Improvements were needed to record keeping systems relating to accidents and incidents, restrictive practice interventions and debriefs to record in detail lessons learned... two people's protocols did not provide enough guidance.
AI Generated
Last inspected: June 2022
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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