Last updated: 9 February 2026
"Staff feel supported and valued with enough people on shift, but serious medication safety failures caused a seizure and activities are very basic."
The lack of effective reconciliation processes had led to the service running out of a person's epilepsy medicines. The person was admitted to hospital after experiencing a seizure following 3 consecutive days without their prescribed medicine.
There was a positive workplace culture at the service. Staff told us that their views were listened to, and they felt supported and valued by the registered manager.
There were enough staff to meet people's needs in a timely and person-centred way. Our observations confirmed this.
Medicine audits were not robust enough to identify the concerns we found with people's medicines. The registered manager was not aware of the concerns identified until we shared the information with them.
A person said, 'There's a young man who comes of a Tuesday who does physiotherapy. He does exercises and throwing a bean bag through the right colour hoop.'
Medication wasn't always given correctly or on time, and running out of epilepsy drugs caused a seizure and hospital visit.
Medicines were not always administered in line with the prescriber's instructions... The lack of effective reconciliation processes had led to the service running out of a person's epilepsy medicines. The person was admitted to hospital after experiencing a seizure
Manager missed big problems with medication safety until inspectors told them.
The registered manager was not aware of the concerns identified until we shared the information with them.
Only basic activities like weekly physio exercises, bean bag games, and some outings to cafes, no special programmes or coordinator.
There's a young man who comes of a Tuesday who does physiotherapy. He does exercises and throwing a bean bag through the right colour hoop... A person had 1-1 support to enable them to participate in activities... visiting local cafes and shops.
AI Generated
Last inspected: June 2023
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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