GHC Nursing Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to safe care and treatment.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have a proactive and positive culture of safety, based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice. We reviewed records such as incidents and accidents, we found there was no processes or systems in place to identify lessons learned or used to drive improvements. For example, we found falls incidents were reviewed by the management team each month. However, action was not always taken to reduce future risks of falls. Records showed multiple people had sustained multiple unwitnessed falls, some resulting in injury. A record demonstrated one person had 11 unwitnessed falls between 15 January 2025 to 31 March 2025. All 11 had not been notified to the local authority safeguarding team and the records failed to demonstrate lessons learnt or what action had been taken to reduce the number of falls. This placed people at risk of harm from injuries relating to falls.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services. People’s care plans and risk management plans were not person centred or always reflective of their care and support needs. This placed people at risk of not receiving safe care and support to meet their needs and manage known risks. We found the preadmission process was not robust. For example, a person who had been at the home for a week, told us they had not been asked about their care and support needs, and their diabetes had not always been managed safely. This resulted in them having a hypoglycaemia. Their care plan had limited written guidance for staff to follow and no evidence of referrals to healthcare professionals were required. Failure to ensure timely referrals were made to external healthcare professionals increased the risk of avoidable harm to people.

The provider did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately. The service did not have robust systems in place to protect people from the risk of abuse and staff failed to always recognise safeguarding concerns. This meant people were at an increased risk of abuse or neglect. For example, we found incident records where people had repeated falls that should have been reported to the local authority safeguarding team that had not been reported. Furthermore, we observed people were at risk of institutional abuse. For example, we conducted an early morning visit and at 6:30am we found 9 people had been supported by staff to have their personal care. A staff member told us “All the people had received support between 5:30am and 6:30am because a member of staff had called in sick for the morning shift, so we helped the morning shift for it to be easier.” Staff failed to recognise this as institutional care, restrictive practice and as a safeguarding concern. Furthermore, we were not assured people had received adequate and safe personal care. There were 4 staff members on the night shift who had supported 9 people with their morning personal care. We were not assured this was accurate as it would not be possible to safely support all 9 people within an hour. Therefore, either people were woken up earlier or people were at risk of neglect and harm from poor personal care. We found incidents and allegations of abuse were not always reported to the local authority safeguarding team and CQC. Failure to report safeguarding concerns to the relevant parties placed people at risk of ongoing safeguarding concerns.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. People and those important to them had not been involved in risk management plans. This meant people were at risk of not being supported in line with their preferences. We found staff were not always provided with clear guidance on how to manage known risks to people. For example, a person who required support with skin damage did not have a risk assessment in place to guide staff with what care and support the person required. Another person was living with diabetes, and we found there was not a person-centred risk assessment in place for staff to follow on how to safely support the person with their diabetes. Furthermore, not all staff had completed diabetes training to ensure they had the right skills to recognise risks. The lack of risk assessments, and training meant staff had no guidance and skills to ensure they could support people safely, this placed people at risk of harm.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Overall, the environment was found to be safe. Health and safety risk assessments such as a fire risk assessment and legionella testing had been completed. However, during the assessment we observed a fire exit that had garden furniture outside blocking the escape route in the event of a fire. This was moved immediately during the assessment.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs. The provider did not have an effective process in place to determine staffing levels to meet people’s care and support needs in a safe way. A dependency record in place was not fully completed on how many staffing hours were required on each shift. A staff member told us staffing numbers were determined from observations completed by the clinical lead. We found no evidence that these observations had been completed. Furthermore, we observed insufficient staffing levels. For example, during lunch time there were not enough staff to support people who required assistance with their food and drink. People who had been assessed as a risk of choking and required staff support to have their meals, were left in reach of their food and drink with no staff supervision. We also found 9 people had been supported with morning personal care and only one person was supported to have breakfast. Failure to ensure an appropriate system and processes to determine staffing levels placed all people at risk of harm and unsafe care due to ineffective staffing numbers to meet people’s needs. Staff were not always competent to ensure they followed their training. For example, staff had completed moving and handling training. However, we observed a staff member use unsafe moving and handling techniques for a person who did not require any staff support. This placed people at risk of harm. Staff were recruited safely. Whist we found concerns during our visit, relatives we spoke to, spoke positively about the care provided. One relative told us, “They [staff] look after [person] very well.”

Whilst the home appeared clean, infection, prevention and control measures in place were not always effective. Parts of the home were in a state of disrepair meaning it could not be cleaned effectively. We found chipped door frames and skirting boards. Internal processes had not identified these areas, or where they had, action had not been taken to rectify and address the issues. Failure to ensure effective infection, prevention and control measures were in place placed people at an increased risk of harm. There was enough personal protective equipment such has gloves available. There was a cleaning schedule in place and followed by staff.

People received their prescribed medication safely. Staff completed relevant training and assessments of competency were carried out by the registered manager to ensure practice was safe. Safe arrangements were in place for the safe storage of controlled drugs. The staff spoken to regarding medicines had an understanding of recognising and reporting any medicines incidents. It was observed that two people were receiving timed medication every three hours and this was appropriately recorded and signed for on their medicine administration record. However, medicines were not always stored safely. We observed prescribed food supplements were left out on the breakfast trolley in the dining room, accessible to others. This placed people living with dementia at risk of harm because people could have access to these products and ingest them. We reported this to the nursing team, and they took immediate action.