critical“During the weeks immediately following this significant event there were not enough staff to meet people's needs and care visits were missed.”
staffing levels
1 finding
critical“A large proportion of staff, including the registered manager and staff responsible for coordinating people's care, had left the organisation.”
governance
1 finding
moderate“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.”
leadership
1 finding
moderate“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.”
record keeping
1 finding
moderate“Care documentation was not always detailed...these omissions increased the risk of errors being made by staff.”
care planning
1 finding
moderate“The transfer to the new electronic record had not been clear for a person and this meant their medicines had not been checked.”
person centred care
1 finding
minor“One person told us, 'I have never been asked for feedback from old or new management.'”
communication with families
1 finding
moderate“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.'”