Garden Hill Care Centre

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 the safe management of people’s medicines.

This service scored 59 (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 listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Learning from incidents and complaints was not always embedded. Incident logs and action plans were in place, but there was limited evidence that themes, such as medication issues, had been analysed and used to improve practice or prevent recurrence.

There were systems in place to support learning,improvement and reflection; however, these were not consistently effective in identifying risks or driving improvement.

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.

Relatives told us they felt overall people’s transition to the home was well managed. People were provided with key information about the service in an information sheet, to inform them and help them settle in.

Staff were provided with an overview of new people and their needs prior to the commencement of their care, via their pre-admission assessment. Staff also had access to up-to-date information about people and key information about them through the handover sheet.

People had emergency admission packs to ensure key information about them could be shared with other services ifrequired, if they needed to be admitted to hospital. Staff were updated about any changes to people’s care at the staff shift handover.

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 improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harmand neglect. The provider did not always share concerns quickly and appropriately.

Staff had completed safeguarding training and knew how to identify and report any concerns appropriately. However, we found insufficient oversight of safeguarding concerns and systems in place were not operated effectively. Although we saw evidence of some safeguarding concerns being reported to the local authority, In some cases, evidence requested by Care Quality Commission (CQC) in relation to concerns was not provided in a timely manner or insufficient or contradictory evidence was provided when evidencing how risks were mitigated.

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 Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We reviewed whether the service was operating in line with MCA principles and how DoLS were managed. Where people lacked capacity to make specific decisions, applications for DoLS had been submitted as required.

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 which was safe, supportive and enabled people to do the things which mattered to them.

Care plans were person-centred and included information about people’s preferences for how they wanted their care and support delivered. However,some care plans were not always up to date or accurate, and risk assessments contained conflicting information. For example, one person’s care plan showed inconsistencies in key areas of risk, including mobility, repositioning, continence, falls, nutrition and capacity. This meant staff did not have clear guidance about the support the person needed, increasing the risk of unsafe transfers, missed care, falls, pressure damage, poor nutrition and unclear consent decisions.In several areas, people were described as independent in care plans despite risk assessments identifying they required support, monitoring or supervision. This put people at increased risk of harm as staff did not have clear guidance about the level of support required.

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 carried out ‘daily walk arounds’ to identify concerns. Improvements within the home were ongoing and regular environmental risk assessments were carried out to help keep the premises safe.

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

Concerns around staffing levels, deployment and oversight were identified. Records showed there had been several incidents between residents, including one incident involving a resident with escalating behaviours in a communal area.There were insufficient staff to provide oversight of communal areas and respond to known risks in a timely manner. This led to the other residents experiencing harm as a result.

Staff were recruited safely and received training relevant to their roles.

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.

Processes were in place and staff were clear about their responsibilities to act if they noticed any concerns in relation to infection prevention and control (IPC). Monthly audits were undertaken and any concerns were addressed within appropriate timescales to meet compliance.

Staff had received IPC training, had access to appropriate Personal Protective Equipment (PPE) and cleaning products were seen to be stored safely. Communal areas and bedrooms were clean and smelt fresh.
 

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

Medicines were stored within locked medicines trolleys and creams were stored securely in residents’ bedrooms. Stock levels checked on the day of inspection were correct and well organised. However, it was noted that there were ongoing issues with stocks being unavailable on numerous occasions. Staff explained this was due to poor communication with the dispensing pharmacy. This appeared to be an ongoing and reoccurring problem that resulted in residents missing their essential medicines each month.

One treatment room was not fit for purpose and had minimal storage space to ensure residents’ supplements were stored appropriately. Temperature monitoring of the medicines rooms and fridges was completed daily by staff. However, some entries had exceeded the recommended guidelines, and no escalation process had been followed.

Staff had not consistently documented the application of creams for residents who were prescribed creams. Duplications were present on the electronic care system, and it was unclear which creams had been applied where residents had numerous creams prescribed. Some cream applications were also documented on the medication administration record (MAR) which created further confusion.

We saw evidence of time critical medicines being given on time, such as those used to treat Parkinson’s Disease. Other medicines which require a gap between doses were given correctly, and documentation was in place if some medicines were not administered for clinical reasons.

Controlled drugs (CDs), which require extra storage and documentation, due to their potential to be misused or abused were managed safely. All entries in the CD register had two staff member signatures and stock levels checked on the day of inspection were correct.