Greenacres Care 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 requires improvement. At this assessment the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to the management of people’s medicines.

This service scored 56 (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 always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

We found that the service did not consistently promote a learning culture that supported safety improvement. Staff did not always understand what constituted an incident and therefore did not always recognise when formal reporting was required. For example, staff did not complete an incident form when a person required medicines to help them manage their emotions when they became distressed, despite this meeting the service’s criteria for incident reporting. This meant there was no evidence of management oversight, post‑incident reflection, or review of the person’s care plan to identify potential triggers or prevention strategies.

Accident monitoring processes were also not robust. Two accidents recorded in the accident log contained no documented actions taken to reduce the risk of recurrence. There was no evidence that the registered manager had reviewed these events or ensured care plans were updated. This lack of oversight meant the service missed opportunities to learn from events and prevent future harm.

Overall, systems for incident reporting, review, and learning were not sufficiently embedded. Staff had limited awareness of the importance of documenting safety‑related events, and management processes did not ensure that lessons were learned or shared. This increased the risk that patterns of risk would go unidentified and improvements would not be made.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

We found that systems to support safe pathways and transitions were generally effective, and staff worked with external professionals to maintain people’s continuity of care. Records showed that when people moved into the home staff gathered relevant information and documented the support provided. This included clear communication with the GP practice, which helped ensure people’s needs were understood and safely managed upon admission.

Feedback from completed professional surveys demonstrated positive communication between the home and external services. Healthcare partners reported that information sharing was timely and that staff were responsive when additional guidance or updates were required. This helped promote coordinated care and supported people through transitions between services.

The provider worked with healthcare partners to understand what being safe meant to people and the best way to achieve that. Staff concentrated on improving people’s lives. However, a lack of training meant staff may not fully understand how to recognise and protect people’s right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

People told us they felt safe in the home and had good relationships with the staff, having a laugh and a joke. One person said, “I feel safe here as it’s all on one floor.”

We found that the service had systems in place to safeguard people from the risk of abuse, and staff generally demonstrated an understanding of their responsibilities to identify and report concerns. However, not all staff had completed safeguarding training, which meant the provider could not be assured that all staff had the required knowledge to recognise and report safeguarding concerns consistently. This increased the risk that potential signs of abuse or neglect might be missed.

Where safeguarding concerns had arisen, the service worked with the local authority and other professionals to investigate and respond appropriately. Staff spoke about occasions when advice had been sought, and records showed the registered manager had engaged with safeguarding partners when required.

Staff were aware of the Deprivation of Liberty Safeguards (DoLS) and understood when an application needed to be submitted. We saw examples where staff had identified changes in people’s capacity and had appropriately raised concerns for assessment. This helped ensure that restrictions were only applied lawfully and in people’s best interests.

Overall, although the service demonstrated appropriate partnership working and awareness of safeguarding processes, the gaps in staff training reflected an area where further improvement was required to ensure safe practice was consistently embedded.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We found that risks to people were generally well‑managed, and staff understood how to support people safely. Care plans contained detailed information about the risks people faced and the measures required to keep them safe. These plans were person‑centred and provided clear guidance for staff, helping ensure that care was delivered in a consistent and supportive way.

People had personalised emergency evacuation plans (PEEPs) in place, which set out the support they required to remain safe in the event of a fire. These documents were available, up to date, and appropriately tailored to individuals’ mobility and support needs.

Overall, while personal risk assessments were detailed and supported safe care, environmental risks were not always proactively identified or addressed.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

People told us they liked the environment. One person said they enjoyed being in a room that overlooked the garden as they spent time looking at the birds.”

We found some environmental safety measures were in place. For example, essential equipment, such as hoists, were safe to use, and records confirmed these had been serviced appropriately. This helped ensure people who required moving and handling support received safe care.

However, the wider environment required improvement. Although the provider had taken appropriate steps to compartmentalise parts of the building for fire safety, several areas of the home were in need of redecoration and general maintenance. This included worn or tired décor that had not been addressed. In addition, we found some environmental risks that had not been fully addressed. For example, uneven flooring leading into the lounge and issues with some vanity units posed potential trip or injury hazards. These had not been previously recorded or mitigated. The registered manager had begun to take action, and the flooring leading into the lounge had been repaired during the assessment period.

Overall, actions taken around equipment safety were positive, but the provider did not always identify or address environmental risks in a timely way. Further improvement was needed to ensure that all aspects of the care environment were safe, well‑maintained, and supported the delivery of high‑quality care.

The provider had enough staff on duty to meet people’s needs, and staff were safely recruited, with appropriate pre‑employment checks in place. However, systems to ensure staff were fully trained and supported were not consistently effective.

People spoke highly about the staff. One person told us, “There is always plenty of staff… they check on me through the night and if anything is not right I tell them and they do something.”

The training matrix showed significant gaps in multiple areas including fire safety, moving and handling, and health and safety. This meant the provider could not be assured that all staff had the skills required to support people safely.

The dependency audit did not show the staffing hours required to meet people’s needs. Although staffing had increased in response to higher dependency levels, this was not reflected within the dependency tool, limiting oversight of whether staffing levels remained appropriate.

Staff supervisions had not been consistently completed, reducing opportunities for staff to receive regular support and review their practice.

Overall, while staffing numbers and recruitment practices were appropriate, gaps in training, supervision and dependency monitoring meant the provider could not consistently assure safe staffing arrangements.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

We found that systems for managing infection prevention and control were not fully effective. The training matrix showed half of the staff had not completed infection control training in the last year. This limited assurance that staff had the required knowledge to reduce infection risks.

People told us they found the home to be clean. One person said, “I just spilt my coffee and they came and cleaned it up for me.”

Some areas of the home were not maintained to a standard that supported good infection control, and environmental issues had the potential to impact cleanliness and hygiene.

The IPC policy was outdated and did not reflect current guidance or recognised best practice. This meant staff did not have clear, up‑to‑date instructions to follow. Evidence from other documents confirmed staff understood some infection control practices, such as using gloves and aprons.

Overall although some infection control measures were in place, gaps in training, policy, and environmental maintenance meant the provider could not consistently demonstrate effective infection prevention and control

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

While people told us they received their medicines as prescribed, we found that medicines were not safely managed and systems to monitor medicines required improvement to ensure safe practice. Weaknesses in the storage, recording and administration systems meant the provider could not demonstrate that medicines were always managed safely.

There was too much stock in the medicines fridge, and the fridge required defrosting, which affected safe temperature control.

Controlled drugs were not safely managed or accurately recorded. The controlled drugs cupboard contained large quantities of medicines, making it difficult for staff to access items safely and promptly. Records were not consistently completed in line with expected practice.

Protocols which supported staff to safely and consistently administer medicines prescribed to be taken as required, such as pain relief, were not accessible to staff at the point of administration. This meant staff did not always have immediate access to guidance about when and how PRN medicines should be used.

Profile sheets were missing, which removed an important safeguard in verifying people’s identity, allergies, communication needs and administration instructions during medicines rounds.

We also found medicines that were not dated when opened, meaning staff could not be assured items were still safe and within their in‑use expiry period.

In addition, drug‑specific administration instructions were not always followed. For example, we found cases where time‑critical or food‑dependent instructions were not being applied as required.

Overall, while people appeared to receive their prescribed medicines, the provider’s systems for storing, recording and managing medicines were not safe. Improvements were needed to ensure medicines were consistently managed in line with best practice and regulatory expectations.