Last updated: 10 February 2026
"People enjoy activities that support their wellbeing, but poor medicines safety, untrained staff on clinical tasks and weak recruitment put them at risk."
People were not always fully protected and kept safe. Medicines were not always managed safely.
We received mixed feedback from staff. Some staff told us they felt supported by management, however other staff told us, “I don’t see management unless I’m in trouble.”
The registered manager did not operate effective and robust recruitment procedures to ensure they employed suitable staff. We found discrepancies with gathering information of full employment history and unexplained gaps.
During our review of daily care records, we identified examples of staff performing clinical tasks without documented evidence of appropriate training or competence. For instance, one person using the service had a catheter in place, and staff were supporting them with catheter bag changes. However, there was no record on the training matrix or elsewhere to evidence this staff had received training in catheter care or had been assessed as competent.
The manager did not have effective oversight of all staff recruitment, training and competency assessments.
People told us they were able to participate in activities, which helped people to maintain their wellbeing. We observed one person was supported to play music, and other people we spoke to told us about their gardening projects at the service. One person told us, “There are two activities people and they’re both really nice. One of them brings in a video tape and we do exercises to it.”
Expired medicines were used and risks like choking or sexual harm weren't managed properly, putting residents in real danger.
During our site visit we found some expired medicines were in use... Despite repeated incidents of people being visited in their rooms without their consent and exposed to sexualised behaviour, the provider did not evidence these events were always investigated without delay
Staff do medical tasks like changing catheter bags without any training records or skill checks.
no record on the training matrix or elsewhere to evidence this staff had received training in catheter care or had been assessed as competent to carry out this task
Recruitment skips full checks on job history and references, so unsuitable staff might get hired.
discrepancies with gathering information of full employment history and unexplained gaps, health questionnaires, evidence from previous employments related to health and social care regarding staff conduct and verifying the reasons for leaving
AI Generated
Last inspected: September 2025
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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