Last updated: 10 February 2026
"Staff feel supported by approachable leadership and work well as a team, but inadequate staffing, medication errors and weak audits hold it back."
Medicines optimisation Score:2 we were unable to reconcile the records for 3 people’s evening medicines. Although staff had signed to say they had given the medicine, a check of tablets showed an overstock. This indicated staff had signed but not given the medicines
Staff told us they found the leadership approachable and worked well as a team. Staff felt they could speak up, saying they worked well as a team and enjoyed supporting people
Safe and effective staffing Score:2 Improvements were needed to ensure there were consistently enough staff on duty. Staffing levels had remained the same for years ... No consideration was given to increased occupancy levels and people’s changing needs
Safeguarding Score:2 although staff received safeguarding training, checks were not in place to ensure staff fully understood how to relate to practice and report concerns
Governance, management and sustainability Score:1 The provider did not have clear responsibilities, roles, systems of accountability and good governance. The provider’s audits and monitoring systems were not robust enough to independently pick up the shortfalls
Per 2018 comprehensive inspection: provided various activities including quizzes, cards and board games, arts and crafts, bingo, and reminiscence
Staffing levels stay the same despite more residents and changing needs, so staff get rushed at busy times and people wait
When the occupancy level had increased from 7 to 9, the staffing levels had remained as 2. This had impacted on staff’s ability to provide the same reassuring support ... Staff felt the staffing levels were not unsafe, but were aware at busy times people may have to wait for staff support
Medication errors happened where staff signed for drugs they did not give, and checks missed them
we were unable to reconcile the records for 3 people’s evening medicines. Although staff had signed to say they had given the medicine, a check of tablets showed an overstock. This indicated staff had signed but not given the medicines. This had not been picked up through the provider’s monitoring system
Manager audits and checks fail to spot risks like falls, unsafe equipment and poor safeguarding, so issues drag on
Audits and checks were not independently picking up risks which placed people at risk of potential harm ... There was no overall analysis of the accident/incidents to support the leadership in identifying any themes ... Safeguarding referrals had not always been made
AI Generated
Last inspected: April 2025
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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