Last updated: 9 February 2026
"Staff feel supported and valued in an approachable culture, but unsafe overnight staffing, poor medicines management and inconsistent training hold it back."
Medicines management processes were unsafe. We found insecure storage, incomplete medicines records, inconsistent monitoring, and a lack of effective audit processes or staff competency assessments.
Staff reported feeling supported, valued, and confident in raising concerns, describing management as approachable and responsive.
Overnight staffing levels did not reflect people’s assessed needs, which increased the risk support might not be provided safely during emergencies or periods of heightened distress.
Training arrangements were inconsistent and did not meet mandatory requirements. Not all staff had completed required training, including the Mental Capacity Act 2005 and the General Data Protection Regulation (GDPR).
The registered manager explained that dual registration across 2 services and being the sole 24/7 on-call manager limited their capacity to implement effective systems.
Staff supported activities including attending day services and engaging in cooking, providing opportunities for skill development and personal choice.
Not enough staff overnight to match residents needs, so you could be overstretched in emergencies or when someone is really upset.
Overnight staffing levels did not reflect people’s assessed needs, which increased the risk support might not be provided safely during emergencies or periods of heightened distress.
Key training like mental capacity act not done by all staff, so gaps in skills for safe legal care.
Not all staff had completed required training, including the Mental Capacity Act 2005 and the General Data Protection Regulation (GDPR).
Medicines stored insecurely with gaps in records, risking wrong doses or errors.
Medicines were not stored securely, including sedative medication. Medication Administration Records contained multiple unexplained gaps.
AI Generated
Last inspected: June 2023
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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