Greenfield View 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.

This is the first assessment for this newly registered service. This key question has been rated 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 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. However, improvements were needed to ensure that learning from incidents was consistently captured, reviewed, and embedded into practice.

The provider had systems and processes in place that recorded incidents and accidents, and records confirmed the actions taken to prevent recurrence. However, there was a lack of analysis to support the provider in identifying clear themes, patterns and trends across the service. This had been identified, and the registered manager showed us a new monitoring tool they were in the process of implementing.

We also identified that the processes for sharing learning opportunities across the staff team required strengthening. While individual incidents were reviewed, there was limited evidence of learning having been shared with the staff team to help embed a culture of continuous learning and ensure that all staff benefited from shared insights and best practices.

People and relatives told us they were informed of incidents and accidents, and how staff made referrals to external professionals for further assessment and guidance. A relative said, “They [staff] had discussions with us and put an alarm mat down in [person’s] room. They’re always keeping an eye on them to make sure they are using their walking frame.”

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. However, the provider’s procedures for ensuring staff had immediate access to important and essential information about new admissions required strengthening. Timely access to this information was critical to delivering safe and effective care from the outset.

During the onsite inspection, a person was transferred into the service. We identified that key information relating to fire safety had not been communicated to staff, posing a potential risk to the individual and others. Additionally, catering staff had not been informed of the person's dietary requirements, risks, or preferences, which could have impacted the safety and quality of care provided.

The provider had systems and processes to share important information with others such as ambulance and hospital staff. This included information about people’s individual care needs, preferences, including advance decisions to enable consistency in care delivery as people moved between services.

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, however, had not always shared concerns quickly and appropriately.

We identified some examples where the registered manager had not reported safeguarding incidents to us, as required. This is important information to enable us to monitor services. The registered manager told us this was an oversight on their part and had learnt from this.

Safeguarding information had been made available to people and visitors. Overall, people and relatives were positive about safety. A person told us, “The staff explain things to me to keep me safe.” A relative said, “I feel confident [person] is cared for safely.”

Staff had access to the provider’s safeguarding policy and had received safeguarding training. Staff demonstrated they understood their role and responsibilities in keeping people safe from abuse and avoidable harm. A staff member said, “It’s staff’s responsibility to record and report any concerns about abuse, I haven't seen anything that concerns me, but I'm aware of my responsibilities and would report straight away.”

People were protected lawfully in line with the Deprivation of Liberty Safeguards (DoLS). The provider had a DoLS policy and procedure, and staff had received required training. DoLS care plans informed staff of the authorisation and expiry date and details of any conditions. Where conditions had been made, we found these had been met.

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. However, we identified examples where best practice in assessing and mitigating risks had not been followed. Whilst this had not caused harm to people, there was a risk of potential harm.

Where people had a diagnosis of diabetes, they had a care plan that provided staff with important information and guidance on how to support the individual and manage the health condition. However, no risk assessment had been completed, despite NICE (National Institute for Health and Care Excellence) guidance recommending an assessment of risk to be completed. We also noted that care plans did not include information relating to eye and nail care, which are important aspects of diabetes management.

A person was receiving dialysis treatment at the hospital three times a week. However, there was no care plan or risk assessment outlining when and where the person attended their outpatient appointments, the support they required post-treatment, or any potential risks. This information was important to help staff understand and respond to the impact of the treatment.

Visiting healthcare professionals provided positive feedback about how people were supported with their diabetes. They also told us they had no concerns about safety and how knowledgeable and competent they found staff to be.

Relatives also raised no concerns about safety and spoke positively of how well their relation was cared for describing staff as, “excellent.”

Staff were found to be knowledgeable about people’s individual care needs and associated risks. However, some staff told us they felt information and guidance in care plans and risk assessments could be improved. Staff were confident people received safe care.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The provider had relevant health and safety policies and procedures to ensure the service, premises and equipment were serviced, maintained and monitored. The fire service completed a fire safety audit in 2024, and the service was broadly compliant with no follow up actions required. Where recommendations had been made, we saw these had been met.

Risks in relation to fire safety and legionella; a water-based bacteria that can cause serious illness, were assessed, mitigated and monitored.

Staff had received fire safety related training. Personal emergency evacuation plans were in place and fire checks and drills were completed to ensure people would be supported safely in the event of an emergency evacuation.

The provider had an ongoing refurbishment plan to further develop and improve the environment.

The provider had not consistently made sure there were enough qualified, skilled and experienced staff available. Improvements had been made and were ongoing in ensuring staff received effective support, supervision and development. Additional staff were being recruited.

Communication within the staff team was identified as an area requiring improvement. The daily staff handover, which was used to share and exchange information about people’s care and treatment, lacked sufficient detail and quality in the information recorded. Additionally, there was limited management oversight of this process. We discussed these concerns with the registered manager, who acknowledged the issues and took immediate steps to make improvements.

We were not fully assured that staffing levels were sufficient to meet people’s care and safety needs. The provider used a dependency tool to assess individuals’ needs and determine appropriate staffing levels. However, in practice, care staff were required to undertake additional responsibilities beyond direct care, such as preparing and serving the evening meal after the cook went off duty, and facilitating activities for people using the service. These additional duties were not accounted for within the dependency tool, raising concerns about whether staffing arrangements were adequate to meet the full scope of expectations placed upon care staff.

We discussed staffing arrangements with the registered manager and provider. They confirmed and provided assurance of actions taken to improve staffing levels. Roles for catering, care, and domestic staff had been advertised and were in the process of being recruited. Volunteers were also being recruited to support the delivery of activities. The registered manager told us they covered any staff shortfalls when necessary.

Staffing levels were raised by some staff as being a concern. Staff told us they struggled at busy times and asked the management team to assist which they did.

Overall, people and their relatives expressed confidence that there were enough staff available to meet people’s needs, although they acknowledged how busy staff were. One person said, “The staff are busy all of the time, but they are very good.” A relative commented, “There’s enough staff and they are on their toes.” However, some concerns were raised about staffing levels during evenings and weekends, and the impact this had on people waiting for assistance. We shared this feedback with the management team, who agreed to follow up.

Our observations found that staff responded to people’s requests for assistance in a timely manner. Although staff were not always present in communal areas, people were left unattended for minimal periods of time.

Staff were positive about the support they received and confirmed they received opportunities to discuss their work, training and development needs. The supervision matrix confirmed the staff met with the registered manager and this had increased in frequency from 2024.

Staff were recruited safely. Appropriate checks were carried out before employment, and only suitable staff with the right skills and experience were employed. Induction training was provided to new staff and this included ‘shadowing’ experienced staff.

Staff received ongoing training, and the training matrix showed good compliance. Staff had received a wide variety of training to meet the needs of people, and their competency had been assessed in several topic areas, including medication, moving and handling, and dignity.

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 local authority completed an infection prevention and control audit in March 2025, in which the provider achieved a score of 90%. Where shortfalls had been identified, these had been addressed.

During our visit, we raised concerns with the provider about having only one domestic staff member on duty each day. Given the size of the service and increasing occupancy levels, we were not assured this was sufficient to maintain cleanliness and hygiene standards. The provider acknowledged this and confirmed that recruitment for additional domestic staff was underway.

The provider had an up-to-date infection prevention and control policy, and staff had received relevant training. Areas of the service were visibly clean overall. Staff had access to personal protective equipment and demonstrated knowledge of safe waste management practices. Domestic staff followed cleaning schedules aligned with best practice guidance, and systems were in place to monitor cleanliness and hygiene.

People using the service and their relatives did not raise any concerns about cleanliness or hygiene. One relative shared that they had previously raised concerns, and improvements had since been made. This was confirmed by the management team, who outlined the actions taken in response.

The provider’s systems and processes did not always ensure that medicines and treatments were safe or met people’s individual needs. Although no one had come to harm, there was a risk of potential harm.

We identified that medicines classified as ‘high risk’ did not have an associated care plan or risk assessment, as recommended by NICE guidance and the provider’s medicines policy and procedure. Despite this, the registered manager and a senior carer we spoke with were aware of the risks these medicines posed, particularly in the event of a fall and the actions required, such as seeking medical attention. After bringing this to the attention of the registered manager, action was taken to implement the relevant care plans and risk assessments.

When people were prescribed ‘as and when required’ (PRN) medicines, protocols were generally in place to guide staff when to administer them. In one instance, we identified a missing PRN protocol; however, the person’s medicine care plan referenced the PRN and included guidance on safe administration. We discussed this with the registered manager who took immediate action. However, following the inspection, the provider forwarded us evidence that this PRN protocol was available for staff.

Where a person was prescribed a transdermal patch that delivers medicine directly through the skin, there was no risk assessment advising staff on the importance of patch rotation to avoid skin irritation. Nor was there guidance on the need to check that the patch remained in place. While the registered manager and senior carer were aware of these requirements, it was important that this information be documented to ensure consistency in care and treatment.

Medicines were ordered, stored, and surplus stock returned in accordance with best practice guidance. Systems and processes, including management oversight, were in place to continually review and monitor how medicines were managed, and action was taken when medicine errors occurred. A clinician from the local GP practice visited the service weekly and conducted annual medicine reviews, or more frequently if required. During a sample stock check, we found a discrepancy of two tablets that could not be accounted for. This was discussed with the registered manager for investigation.

Staff had received training in the safe handling of medicines, and their competencies were regularly assessed. We observed a medicine round and saw that medicines were administered safely and effectively