Greenhill Park 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.
The service was in breach of legal regulation in relation to safe environments and medicines management.
 

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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.
People and their relatives told us they felt safe living in the home and any concerns raised were listened to and acted upon. People were confident about who they could speak to if they ever felt unsafe. We observed positive and respectful interactions between people and the management team. Several people told us they would approach the manager directly if they had any worries or concerns.
One person told us, “I enjoy it here, it’s nice and I’ve got good friends here. We get well looked after, I’m clean and tidy. Everyone talks to one another, and I just enjoy being here.”
One relative told us, “Management are always around and the registered manager is very approachable.”
The registered manager routinely reviewed accidents and incidents in a timely manner. Documentation showed the registered manager reviewed each event to consider how people could be supported safely and how risks could be reduced going forward. Lessons learned were recorded in a central plan and shared with the wider team to support continuous improvement and reduce the likelihood of similar incidents occurring again.
 

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 had systems in place to support people when moving into the service, and clear procedures outlining the actions required should someone need to transition out of the home. These arrangements helped ensure pathways of care were safe, well‑coordinated and responsive to people’s needs.
The home used an online care‑planning system, and when a person needed to attend hospital, staff could generate a hospital passport containing key information about their needs, preferences and communication methods. This helped ensure essential details were shared promptly with healthcare professionals, supporting safe and well‑coordinated care during transitions.
 

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.
People told us they felt safe living in the home. One person told us, “I know all the care homes in the area in comparison with this one. I chose this one first and I am treated like a human being.”
One relative told us, “Management are always around and the registered manager is very approachable. My relative is safe living here.”
Staff demonstrated a good understanding of how to protect people from harm and abuse. Staff were provided with up‑to‑date safeguarding training. Staff told us they felt confident in recognising concerns and knew the correct procedures for reporting and escalating any safeguarding issues to ensure people were kept safe.
The home had a safeguarding policy in place which is reviewed in line with the management team’s monthly audits.
 

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.
We found examples where risks relating to safety, health and wellbeing had not been effectively assessed, monitored or reviewed. We observed environmental risks that had not been fully addressed, including exposed hot water pipes and unsecured fixtures and fittings, which increased the risk of injury through trips and burns. We also identified missing window restrictors in some areas and unrestricted access to certain parts of the building, creating a potential risk of falls for some people.
The provider had systems in place to identify risks; however, these were not always implemented effectively, resulting in inconsistent practice and placing people at potential risk of harm. As a result, we could not be assured people were always fully involved in decisions about managing risks associated with their care and support.Staff worked alongside people to understand what was important to them and supported them to make informed choices about their care. The care plans we reviewed were person‑centred and included detailed information about each person’s history, preferences and what mattered most to them.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.
During the assessment, we found aspects of the environment were not consistently maintained in a way which ensured people’s safety. We observed exposed hot water pipes, unsecured fixtures and fittings which presented a trip hazard and potential risk of burns to people. Additionally, there were missing window restrictors in some areas, and unrestricted access to parts of the building which posed a potential falls risk for some people. These concerns were raised with the registered manager during our visit, and immediate actions were taken to reduce some of the risks.We asked the provider for an action plan in response to the concerns found at this assessment. The provider was responsive to this request and produced an action plan, together with completion dates on when issues identified would be addressed. We were assured by the work that had been completed and the rest was scheduled for completion. We look forward to seeing the completed work in its entirety at the next inspection.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.
The provider followed safe recruitment practices. Records we reviewed showed appropriate pre‑employment checks had been completed before staff started work. These included verification of employment history, obtaining suitable references, and carrying out Disclosure and Barring Service (DBS) checks. A DBS check helps ensure staff are of good character and safe to work with people using the service.
One person told us, “The staff are very good. We get well looked after. They do their best. They ask if I want any care when I’m getting up.”
A relative told us, “The staff, the attention they have is good. They are great people.”
A member of staff told us, “The team work well together, there is good communication within the team.”
Supervision records showed staff were receiving regular supervision and appropriate support to carry out their roles effectively. Review of staffing rotas demonstrated staffing levels were consistently maintained and planned in line with the needs of people living in the home.
 

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.
The service had an Infection Prevention and Control (IPC) policy and procedure in place, and regular IPC audits were being completed. However, these audits were not fully effective, as they had not identified several concerns we found during our assessment.We observed unclean areas within bathrooms, unsuitable materials stored in areas requiring strict hygiene, and staining present in parts of the home environment. Refurbishment plans were shared with us, and we look forward to seeing these improvements at our next inspection.
We were informed, and records reviewed assured us, the home had a refurbishment plan in place to address areas requiring improvement.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.
During our assessment, we found people’s ‘as required’ (PRN) medication protocols were not always being followed. When reviewing one person’s care records, we identified staff had not supported them in line with the guidance set out in their PRN protocol. Although there was a designated person responsible for monitoring PRN usage, this issue had not been identified. This put the person’s health and safety at risk. We raised this with the management team, who were previously unaware but assured us they would take immediate action to review and address the concern.
We also found some prescribed shampoo medicines were not securely stored, and there were medications present which belonged to people who no longer lived at the home. These medicines were also accessible to people living in the home. These were removed during the assessment and handed to the registered manager for appropriate return and disposal. In addition, some medicines did not have recorded opening dates, meaning staff were unable to monitor expiry effectively.
Training records showed staff had received appropriate medication training. Competency assessments were also completed following training and included direct observations and knowledge checks before staff were permitted to administer medicines independently.
The home worked collaboratively with external healthcare professionals, including the local GP and community nursing team, to ensure medication care plans were kept up to date and reviewed regularly.