Note5 Apr 2023
At time of inspection, sufficient staff were in place and a weekly rota with names and times provided to families.
Note5 Apr 2023
Professionals reported positive working relationships with the new management team and praised their responsiveness.
Note5 Apr 2023
New senior team developed a robust action plan and implemented monitoring systems including audits and quality assurance.
Note5 Apr 2023
Staff understood infection prevention and control procedures, including appropriate use of PPE.
Note5 Apr 2023
Medicines administration training and competency assessments were in place; senior team audited medicines promptly.
Note5 Apr 2023
Staff received safeguarding training and demonstrated confidence in recognising and reporting concerns.
Note5 Apr 2023
Provider kept CQC informed throughout, with transparent communication about actions taken and their impact.
Note5 Apr 2023
Provider worked proactively with the local authority to manage the staffing crisis and reduce risks to people.
moderatecommunication_with_families5 Apr 2023
People and relatives were unsettled by this change and we heard numerous comments such as 'I have no idea who the manager is, I have heard lots of changes.'
minorperson_centred_care5 Apr 2023
One person told us, 'I have never been asked for feedback from old or new management.'
moderatecare_planning5 Apr 2023
The transfer to the new electronic record had not been clear for a person and this meant their medicines had not been checked.
moderaterecord_keeping5 Apr 2023
Care documentation was not always detailed...these omissions increased the risk of errors being made by staff.
moderateleadership5 Apr 2023
A temporary manager had been put in post...then a permanent manager was appointed who did not stay in post. A new manager had been appointed the week before the inspection.
moderategovernance5 Apr 2023
Work to transfer people's care documentation to the provider's new system had not happened effectively...new managers were not always accessing the most up to date information easily.
criticalstaffing_levels5 Apr 2023
A large proportion of staff, including the registered manager and staff responsible for coordinating people's care, had left the organisation.
criticalmissed_or_late_visits5 Apr 2023
During the weeks immediately following this significant event there were not enough staff to meet people's needs and care visits were missed.