Greenacres Care Home

Updated 12 January 2026

The assessment started on 15 January 2026 and was completed on 23 February 2026.

The assessment was completed due to the length of time since the previous inspection.

The provider was in breach of the legal regulations relating to safe care and treatment, consent and good governance.

The service delivered caring day-to-day support, but there were significant weaknesses across safety, leadership and governance that affected the overall quality and reliability of care. Although individual staff were compassionate, the systems needed to ensure safe, consistent and well managed care were not embedded or sustained.

Risks around the environment, infection control, medicines and supporting people’s rights were not consistently identified or addressed. Mental capacity assessments were missing when restrictive practices were used, meaning people’s rights were not always protected. Medicines management systems were unsafe: medicines profile sheets were missing, controlled drugs were poorly recorded, guidance for staff on how and when to administer medicines prescribed to be taken as required, such as painkillers were inaccessible. The level of stock in the medicine’s fridge was excessive and increased the risk of stock being out of date. Although there was no evidence of missed doses, these issues created potential avoidable risk. Environmental risks had not been fully addressed, and infection control arrangements were weakened by outdated policies, incomplete training, and lack of clear cleaning schedules. Staffing systems were also ineffective: training gaps were significant, supervisions were not consistently completed and the dependency tool did not evidence how staffing levels matched people’s needs.

Governance and oversight systems were not effective. Audits failed to identify obvious concerns, action plans lacked timescales, and there was limited provider‑level monitoring. Some basic safety processes that had previously existed, such as medicines profile pages and routine mental capacity assessments had not been sustained. This indicated a lack of continuous learning, improvement or modernisation.

Updated 12 January 2026

People told us they were happy with the care they received, and survey feedback reflected high satisfaction. Staff interactions we observed were warm and respectful, and people were supported to make choices and maintain independence in daily routines. Care plans also showed people were encouraged to continue meaningful activities and manage aspects of their own health where safe.

However, several shortcomings within the service had the potential to negatively affect people’s experience. Missing mental capacity assessments meant some people’s rights were not fully protected. Medicines systems were poorly managed, including missing profile sheets, inaccessible PRN protocols, excess stock, and weak controlled drug processes, which created potential avoidable risk even though people appeared to receive their prescribed medicines.

While day‑to‑day care was caring and supportive, the weaknesses in governance and oversight meant people could not be fully assured that safe and consistent standards would be maintained over time.