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 inadequate. 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.

The provider was previously in breach of the legal regulations in relation to safe care and treatment, premises and equipment, and governance. Improvements were not found at this assessment, and the provider remained in breach of these regulations.

This service scored 47 (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 identify and escalate concerns about safety, and the service did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

We found incidents and accidents were monitored, but reviews did not identify learning or drive improvement. Lessons learnt sections were often left blank and learning was not routinely captured. Opportunities to prevent repeat incidents were missed. Concerns identified at the previous assessment had not been fully acted on showing learning was not consistently applied across the service.

However, we did see aspects of an improved learning culture and staff said, “Ihavefelttheowneris now reallylistening andison board and is nowimplementingthings” and “We have beenhaving lessons learnt so we willlookatwhathappened andwhat we couldhave done better.”

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.

Before providing care, the provider’s process is to obtain relevant information from social workers, brokerage teams, families and if relevant other providers involved in the person’s care and support, to ensure safe and consistent support.

We saw improvements in documentation within people’s care plans, including clearer involvement of relevant professionals. Staff understood their responsibilities and we saw appropriate liaison with GPs and other services supporting people when moving to or from the service.

Before providing care, the provider’s process is to obtain relevant information from social workers, brokerage teams, families and if relevant other providers involved in the person’s care and support, to ensure safe and consistent support.

People were not always fully protected from the risk of abuse because safeguarding systems were inconsistently applied.

Gaps in care planning and record-keeping meant staff did not always have the right information to protect people from neglect or harm. Safeguarding concerns were not reliably identified through routine audits or reviews, limiting the service’s ability to learn and prevent further incidents.

Staff understood their safeguarding roles and most knew how to escalate concerns. One staff member said, “If IwitnessedanythingI wouldreportitto themanager andthen gooutsidetheorganisationifnoactionwas taken-notsure whothat wouldbe,but I would find out.”

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found appropriate use of DoLS tracking, and the service had policies in place.

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

Key risk assessments were missing, out of date or lacked the detail staff needed. This included moving and handling, and environmental risk assessments. People’s care plans did not always reflect their current needs, particularly for those requiring repositioning or close monitoring of hydration. These issues represented ongoing concerns identified at the last assessment, showing a lack of improvement and oversight. For example, the registered manager was not involved in creating the care plans and did not audit them after completion to ensure all relevant, up-to-date information was included.

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

The provider did not always detect and control potential risks in the care environment. They did not make sure equipment, facilities and technology supported the delivery of safe care.The environment was not consistently safe, and several hazards placed people at risk of avoidable harm.

We identified an uncovered hot radiator, oil‑filled radiators with no risk assessment, windows without restrictors, and fire doors which did not close fully. These issues represented unresolved concerns from the previous assessment.

Environmental audits were inconsistent and did not identify the hazards we found. These issues showed a lack of effective oversight and created significant environmental risks. For example, we had discussed the unrestricted windows and risk of fall from height with the registered manager and provider, yet they had not actioned this fully or picked up that it had not been actioned on their checks or audits.

This contributed to the breach of regulation in relation to safe environments.

The provider did not always make sure there were enough staff. They did not always make sure staff received effective support, training, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

Staffing was not always planned or monitored in a way which ensured people received safe and consistent care. Staff told us there continued to be pressure on staffing levels, one staff member said, “Sometimeswe do feel short staffed.” The dependency tool did not set out how many staff were needed on each shift. Several staff lacked essential training, including moving and handling, equality, diversity, privacy and dignity. Fire training had not been completed by some night staff, and some had not taken part in fire drills.

Despite this, staff were positive about morale and told us they felt supported. We saw staff interacting kindly with people and using their knowledge to support them. However, gaps in training, supervision and staffing analysis show improvements are still required.

Safe recruitment practices were being followed. Most Staff had references and Disclosure and Barring service (DBS) checks, as required. DBS checks provide information, including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

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 some effective infection control measures, but key gaps meant people were not always protected from infection risks.

We found a commode was emptied and replaced for use without appropriate cleaning, PPE was not used correctly, and some cleaning tasks were not consistently recorded or audited. The presence of a cat in the kitchen had not been risk assessed despite us sharing this concern at our last assessment, and food safety paperwork was not up to date. These issues showed inconsistent application of infection control practices.

However, there were some improvements, and we could see where staff had made changes. Staff said, “They haveplentyof PPEwhereasbeforethat was nothappening” and “We now have all thecolourcodedbuckets.” We saw evidence of legionella checks and regular cleaning records, and the premises were generally cleaner than during the last inspection. Laundry improvements had been planned to further reduce infection risks.

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

Medicines were not always managed safely, and people were at risk of not receiving medicines as prescribed. Topical creams were not administered as directed, and ‘when required’ medicines were given without staff recording the times, meaning safe time intervals could not be assured. Staff were not fully aware of the need to record these details.

Medication audits had not identified concerns we found during this assessment. Storage issues, incomplete records and lack of reliable oversight contributed to unsafe practice. Although staff reported verbally handing over PRN times, this did not provide a safe or auditable system. These issues reflect ongoing concerns identified at our last assessment.

People continued to experience inconsistencies in how their medicines were managed. Although audits had taken place, these had not identified ongoing concerns with when-required medicines and topical creams. This meant people could not always rely on the service to support them safely with their prescribed treatments.

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

We spoke with people to learn more about their experiences of using the service. People’s feedback did not highlight any concerns in relation to medication administration.