Archived: Greenview Residential 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 good. At this assessment the rating has changed to 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.

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. The provider and registered manager did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

The provider did not ensure staff always had information they needed to keep people safe. Some policies did not always contain sufficient detail to provide staff with guidance needed to keep people safe. For example, the fire policy and the fire procedure documents contained different information regarding the action staff should take in the event of a fire, this could be confusing for staff and could put people at risk. Additionally, the fire safety procedure document referred to ‘other emergencies’, however it did not detail what these were or how staff should respond other than ‘to take appropriate action’. This did not provide staff with the information and guidance they need to keep people safe.

The provider did not always operate effective systems to investigate and learn from incidents. Incidents were recorded by staff and there was evidence the registered manager reviewed these, however records showed this was not always in a timely manner. For example, some incident reviews were completed 12 months after the incidents. There was no evidence of trends analysis being undertaken and limited detail of actions taken as a result of the incident reviews. This increased the risk of incidents reoccurring.

The provider did not always demonstrate the application of learning following safety incidents. For example, following 1 incident where a person found a dangerous object in the service, there was no evidence awareness and learning had been shared with the whole staff team to prevent reoccurrence.

The registered manager told us there was no service improvement action plan in place and no written evidence was provided of one, this meant there was no record to demonstrate how they identified, monitored and took action to improve the service.

People told us they knew how to raise concerns, and they would speak to the staff, registered manager and provider if they needed to.

Some professional partners told us any suggested improvements they made were listened to and acted upon by the provider.

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.

The provider ensured people’s transitions into and out of the service were safe and appropriate. People and their relatives told us they were pleased with their transition into the service, for example, 1 relative told us they and their loved one were made to ‘feel very welcome’ when they first arrived. They told us they were able to visit the service prior to admission, including when the service held open days and garden parties.

The provider completed initial assessments to ensure the service could meet people’s needs prior to moving in, and people had information passports in place in the event they needed to transition to other healthcare services, such as to hospital. This meant essential information was available to hospital staff to ensure continuity of care.

The provider had a website and a service user guide in place to provide people with useful information to support their transition into the service.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on protecting people’s right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

Systems were not always in place to promote safeguarding. Records showed not all staff had received safeguarding training. There were policies in place to support staff, however, they did not contain reference to current legislation. For example, the policy for safeguarding service users from abuse did not refer to current safeguarding legislation and referred to the Registered Homes Act (1984) which is not current legislation; and the falls policy did not refer to the protocol developed by the local safeguarding adults’ boards for falls, which guides professionals in how to respond appropriately to a fall and how to identify when a fall constitutes a safeguarding concern. This meant staff were not guided and supported by policies containing accurate and up to date information to be able to safeguard people.

Although the registered manager told us how they investigated and reported safeguarding concerns they had not always notified the Care Quality Commission (CQC) when they were required to, for example, when an allegation of abuse had been reported to them. However, the local authority had been made aware, and the registered manager had worked together with them to resolve the concern.

People told us they felt safe and well cared for at the service. For example, 1 person told us they “never felt frightened here” and there were “always people around” which made them feel safe. We observed people to be well cared for and staff and people had positive relationships, with people appearing happy and relaxed around staff.

People who were subject to restrictions on their movements, amounting to a deprivation of their liberty, had the appropriate legal authorisation in place. People’s care plans contained information regarding if they were subject to Deprivation of Liberty Safeguards (DoLS) to provide staff with guidance on how to support people appropriately with any restrictions.

Staff told us they viewed safeguarding as a priority and understood their responsibilities in identifying, recording and reporting any concerns, including evenings and weekends.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff did not always have the knowledge and skills to keep people safe and manage risks associated with their care. Staff had not always completed the service’s mandatory training to keep people safe. For example, not all staff had completed, bedrail safety, dysphagia and choking, food safety and hygiene, and skin integrity training. Additionally, not all staff had completed falls prevention training. This meant people could be at risk.

Staff had not always completed training with regards to people’s specific health needs. For example, not all staff had completed epilepsy training. Documents provided identified this was required training for all staff, and 1 person had a history of seizures. Staff having not completed epilepsy training placed people who had seizures at increased risk of avoidable harm. However, the person’s care plan did state action staff should take if the person had a seizure.

People had care plans and risk assessments in place and risks to people were generally considered and mitigated. However, there was some conflicting information in risk assessments. For example, 1 person was noted to be at severe risk of pressure ulcers in 1 risk assessment, however another risk assessment, for the same person, said they were low risk of pressure ulcers. Additionally, there was unclear information regarding the repositioning frequency for the person. However, when we made the registered manager aware, the person’s care plan was amended.

Staff told us they felt they had the information they needed to understand risks to people and to keep people safe.

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

The provider did not always demonstrate people were effectively protected from the risk of fire. The service did not have a fire risk assessment in place that had been completed by a competent person who has comprehensive training or experience in fire risk assessment. We identified some shortfalls in fire safety, the provider had not picked up, due to the lack of an effective fire risk assessment. For example, some fire doors were not well fitted, and the kitchen hatch did not close in the event of a fire. These meant the spread of fire and smoke may not be prevented in the event of a fire, putting people at risk. However, there was evidence some fire safety checks were routinely completed, such as fire alarm testing, and testing of the emergency lighting system.

The provider did not always demonstrate people were effectively protected from the risk of legionella. The service did not have an up-to-date legionella risk assessment in place that had been completed by a competent person, who understands the water systems and any equipment associated with it, who can assess the risks of hot and cold-water systems, and advise on whether adequate measures are in place to control the risk of exposure to legionella bacteria. Legionella can cause a serious type of pneumonia called legionnaires' disease. We identified some of the water safety checks were not undertaken effectively, meaning there was a potential risk to people from legionella. Staff completing the water safety checks had not undertaken legionella training, however, after we raised this with the registered manager, the staff completed the training. The lack of effective systems and processes around the management of water safety had put people at increased risk of harm from legionella.

Environmental risks to people had not always been identified or mitigated in a timely manner. For example, 2 windows were identified as not having restrictors on, including 1 in a person’s first floor bedroom. This put people at risk of falling from the window. This had been reported by staff 3 months previously, however it had not been repaired. The provider responded to the concerns and window restrictors were in place by the second day of the inspection.

The control of substances hazardous to health (COSHH) was not always safely managed. COSHH items were not always securely stored, for example items were left unsecured in the laundry, an unused bedroom and in the garden, meaning people could access them, putting them at risk of harm from exposure to hazardous substances. 8 of 18 staff had not completed COSHH training despite it being mandatory training for all staff. The COSHH risk assessment was not robust or effective in identifying and mitigating risk. For example, it did not identify the hazardous substances used within the service; and it lacked consideration of control measures to mitigate the risk such as consideration of PPE use, action to take in the event of a spill, appropriate ventilation, staff training, or safety data sheets. However, by the second day of the inspection the provider had removed the COSHH items from the laundry and the unused bedroom and had installed a lockable cupboard to store the laundry items in.

The provider had ensured equipment used for moving and handling and firefighting had been appropriately checked and serviced to ensure it was safe to use.

The provider did not always make sure there were enough qualified, skilled and experiencedstaff.

Records showed not all staff had completed all training for their role, as mandated by the service. For example, there were significant gaps in staff training records for bedrail safety, dysphagia and choking, food safety and hygiene, skin integrity and pressure ulcers, epilepsy, COSHH and medicines. Additionally, not all staff had completed falls prevention training and staff who were responsible for water safety checks had not completed relevant training. These are highlighted throughout this report.

The recruitment policy did not contain sufficient details of safe recruitment in line with regulatory requirements, and the provider did not always provide complete records of the checks they completed for staff recruitment to evidence they were recruited safely. We have included further details of the shortfalls we found in staff recruitment processes in the well led section of this report.

However, people told us they felt there were enough staff, and they knew and understood people’s needs. Staff told us they felt there were enough staff and although busy, they felt they had enough time to spend quality time with people. We observed there were sufficient staff and work rotas showed enough staff were deployed to meet people’s needs.

Staff received an induction when they started, including shadowing existing staff, competency assessments and observations of their practice. They received supervision and appraisals, although the frequency of these was unclear as relevant policies did not identify the required frequency. However, staff and management had positive relationships and staff said they could speak with the management when they needed.

Where staff performance was impacting the service, disciplinary processes described to us appeared fair and were completed with a supportive approach from the registered manager, reducing the impact on the people, staff and the service.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service appeared clean and well maintained. The kitchen and laundry both appeared clean and there were no malodours identified within the service. Personal protective equipment (PPE) was available throughout the service and staff were observed to use it appropriately to prevent cross contamination and infection. Staff told us there was a laundry separation system in place which we observed them following, which avoided cross contamination of laundry items.

Most staff had completed infection prevention and control (IPC) training meaning they had the skills and knowledge to ensure the service was kept clean.

Hand gel dispensers by the main front and rear entrances did not work meaning staff and visitors were not able to sanitise their hands immediately upon entering the building, however there were handwashing facilities available within the service.

There was an IPC policy in place, however it used some ambiguous wording around cleaning. For example, it stated some areas should be cleaned “more frequently”, “regularly” and some rooms required “special attention”, without specifying what these terms meant. This meant there was a risk these cleaning tasks may not be completed as required.

The registered manager told us cleaning records were not currently in place, which was inconsistent with the service’s IPC policy, and meant management oversight could be impacted, although they reinstated these after the inspection. However, we observed staff cleaning the service throughout the inspection.

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

Medicines were not always administered safely. Medication was not prepared by the staff member administering it. Medicines were prepared for all people, once per week, by 1 member of staff and then individual staff administered the medicines at the time they were due. The staff administering the medication therefore did not know what medication they were administering as they had not prepared it.

1 person’s medicine did not have a medication box or prescription label, as it had arrived in a dosset box in which the medicines had already been dispensed away from the service and not by staff or a pharmacy. This is a risk as staff did not know what medicines they were administering to the person.

These are examples of secondary dispensing, and this increases the risk of medication errors, which is not in line with best practice.

We highlighted this to the registered manager, who took immediate steps to resolve the practice. They rapidly arranged with a pharmacy for prescribed monitored dosage systems to be put in place for each person. This reduced the risk to people of medicines errors occurring.

Records showed 1 member of staff who was administering medicines had not received medicines administration training or a medicines competency assessment within the past 12 months. However, when we highlighted this, the registered manager ensured this staff member subsequently completed medicines training. Although the registered manager and most staff had completed medicines training, the training had not been effective as they had not identified the risks associated with secondary dispensing.

Medicines were not always stored safely. Medicines awaiting disposal were found in an unsecured container in an unlocked cupboard in a communal bathroom people could access. However, when we shared this with the registered manager, they took immediate action to make this safe. Other medicines, including controlled medicines werestored securely with access restricted to authorised staff.

Two medicines were identified as being out of date in the medicines trolley, however the registered manager took action to resolve this immediately when we identified it to them.

The systems in place to audit medicine practice were not effective. Audits were completed by a senior member of staff however there was no recorded management oversight. These audits were not effective as they did not identify the concerns with medicines we found during the inspection.

People’s records contained information about how they preferred to take their medicines, and they had individual protocols in place for ‘as required’ (PRN) medicines, which contained appropriate information about when these medicines should be administered. These medicines were administered safely.

Records were kept showing when medicines had been administered or refused. Controlled medicines were safely managed and recorded.