Garsewednack Residential 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 inadequate.

This meant people were not safe and were at risk of avoidable harm.

The provider and registered manager were in breach of the legal regulation relating to safe care and treatment, governance and premises and recruitment.

This service scored 28 (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. The registered manager did not always listen to concerns about safety. Lessons were not always learnt to continually identify and embed good practice.

We reviewed incident and accident records. The registered manager told us these were reviewed monthly. However, the reviews were not always effective or robust. For example, the “lessons learnt” section was often left blank, and one review failed to record an injury sustained after a fall.

This contributed to a breach of regulations relating to safe care and treatment and governance.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services. The systems in place did not identify all the concerns we found at this inspection.

We found one person’s medical guidance, provided by a medical professional, was not being followed. This placed the person at risk of choking and aspiration. When we spoke to staff about the person’s food and fluid needs, they were unsure whether a modified diet and thickened fluids were required. The registered manager was also unaware of the person’s needs. We advised them to contact a medical professional and the local authority safeguarding team.

This contributed to a breach of regulations relating to safe care and treatment.

The provider did not always concentrate on improving people’s lives or protecting their right to live safety, free from abuse, avoidable harm and neglect.

During our assessment, we identified a person was at risk of avoidable harm and neglect. We asked the registered manager to make a safeguarding referral to the local authority. For more information in relation to avoidable harm see safe systems, pathways and transitions.

We found the service was holding people’s finances, which was not included within people’s care plans and risk assessments. This decision was not in line with the Mental Capacity Act 2005. For more information in relation to decisions see consent to care and treatment quality statement.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes and hospitals, this is done through the Deprivation of Liberty Safeguards (DoLS), part of the Mental Capacity Act 2005 (MCA). We checked whether the service followed the principles of the MCA and how it managed DoLS. Although the service had applied for DoLS authorisations, people’s care plans lacked information about the purpose of the DoLS. There was no clear guidance for staff on the restrictions in place or how these affected people’s care.

While we did not identify anyone who had come to harm, this contributed to a breach of the regulation relating to consent and governance.

Staff told us they would report any abuse to the registered manager, and if no action was taken, they would escalate concerns to the police or local authority. People told us they felt safe at the service. One relative told us, “I do believe he is safe in this residential home”. Another told us, “I do believe she is safe and comfortable”.

The provider did not 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 one person’s guidance, provided by a medical professional and nationally recognised guidance was not always followed. This placed the person at risk of choking and aspiration. When we spoke to staff about the person’s food and fluid needs, they were unsure whether a modified diet and thickened fluids were required. The registered manager was also unaware of the person’s needs. We advised them to contact a medical professional and the local authority safeguarding team.

The provider did not take all reasonably practicable steps to mitigate risks. For example, risks associated with bedrails and moving and handling had not been assessed, mitigated, or managed. As a result, care plans contained limited information to guide staff in delivering safe and effective care.

This contributed to a breach of the regulation in relation to safe care and treatment and governance.

A relative told us, the service communicates well with them. The staff and management will contact regularly about any changes in the person’s day.

The provider did not consistently identify or manage environmental risks.

The service failed to protect people from hazards linked to the premises and was not following current legislation and guidance. For example, most first-floor rooms lacked tamper-proof window restrictors, placing people at risk of falling from height. The registered manager and provider told us they were unaware of the Health and Safety Executive guidance published in 2014.

The service also failed to manage fire safety risks. Several fire doors did not fully close, increasing the risk of harm from smoke and fire. Although fire drill records were available, they did not show that evacuations had been discussed or carried out. One staff member told us, “I don’t think we have any kind of drills”.

An external fire risk assessment had been completed, but not all required improvements had been actioned. Some environmental risk assessments were missing or out of date, and measures to reduce the risk of burns had not been implemented.

Although Legionella check records were in place, they had not been completed. This exposed people to increased risk from Legionella disease.

While completing the SOFI, we noticed two staff members tripping over a cat in the lounge; this risk had not been assessed, mitigated or managed

Whilst we did not identify anyone who had come to harm, this contributed to a breach of regulations relating to premises and equipment and governance.

Relatives told us there could be some improvements with the environments. Comments included, “Maybe it could be improved with new coat of paint, it's tired looking but cosy,” and “Décor could be maybe improved, but it is totally irrelevant when my relative is happy in there”.

The provider did not consistently ensure there were enough qualified, skilled, and experienced staff to deliver safe, person-centred care. Staff did not always work effectively as a team to meet people’s individual needs.

Staff told us they were sometimes unable to carry out their roles due to staff sickness and a lack of support from the management team. Feedback from staff was mixed regarding whether there were enough staff to meet people’s needs.

Although the service used a dependency tool to assess the level of support people required, the registered manager and provider told us this did not account for the time needed to meet those needs.

People and relatives also gave mixed feedback about whether staffing levels were adequate. Comments included, “Not always, they can be busy”, and “A couple of times, they are short of staff”.

Safe recruitment practices were not always followed. Two staff members had not received Disclosure and Barring Service (DBS) checks, as required by the provider’s own policy. DBS checks help employers make safer recruitment decisions by identifying criminal convictions or cautions. Since the assessment, the service has completed DBS checks for both staff members.

Whilst we did not identify anyone who had come to harm, this was a breach of regulation relating to recruitment.

Staff told us they received regular supervision, and records confirmed this.

One relative told us, “Staff are very kind to him and he seems relaxed with staff, they banter and they make him smile”. Another told us, “Carers are brilliant, I can’t fault them”.

The provider did not assess or manage the risk of infection effectively and failed to detect or control the risk of it spreading.

We observed approximately 50 bags of clinical waste piled in the car park. The registered manager was not following the provider’s policy, which states that “yellow sacks (clinical waste) should be sealed and stored safely to await collection by an authorized collector”. This exposed people, staff, and the public to the risk of infection and cross-contamination. Since the site visit, the provider has assured us measures have been put into place for the removal of the surplus waste, and a new waste management regime is now in place.

The laundry area did not have a clear segregation of clean and dirty items, to ensure staff and people were protected from contamination of linen.

The premises were not clean or free from odour. Cleaning schedules provided by the registered manager had not been completed since November 2024. Although some care staff were seen hoovering and recording this in people’s daily notes, the registered manager acknowledged the issue but had not taken sufficient action to address it.

On the first day of our unannounced visit, parts of the service had a strong, offensive smell of urine. This contributed to a breach of regulations relating to premises and equipment.

A staff member told us about the cleaning routines in the kitchen, and records confirmed these were completed daily. Another staff member told us, “With infection control, we have stocks of PPE (Personal Protective Equipment) on each floor. We have hand sanitise and do colour codes for cleaning equipment, and we sanitiser throughout the home. Every time I [support a resident] I will always change everything, gloves and apron".

A relative told us, “(Person’s name) room is tidy”.

The provider did not ensure that medicines and treatments were safe or aligned with people’s needs, capacities, and preferences.

Topical medicines, such as creams, were recorded on topical charts but were not always administered in line with prescriber instructions. Medicines Administration Records (MAR) were not consistently completed in accordance with the provider’s policy. For example, the policy states, “once delivered, all medication will be checked in against what has been ordered to ensure that quantities and instructions are as directed by the GP”. But this was not always followed, which meant monitoring people were receiving their medication could not always be achieved.

Records for “when required” medication were not completed in line with NICE guidance on managing medicines in care homes. This placed people at risk of being overmedicated.

Staff carried out weekly medication audits, and the registered manager completed a monthly audit, last recorded in July 2025. However, these audits were ineffective and failed to identify the concerns found during this assessment.

Whilst we did not identify anyone who had come to harm, this contributed to a breach of regulation relating to safe care and treatment.

A relative told us, “All (Person’s name) meds are managed by staff, and that’s what we liked”.