Georgina House

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 requires improvement. At this assessment the rating has remained 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 provider was in breach of legal regulation in relation to safe care and treatment.

At our last inspection, the provider was in breach of legal regulation regarding the safety of the premises and equipment. However, some improvements were found at this assessment, and the provider was no longer in breach of this regulation.

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.

Staff had not always appropriately recorded patterns of people’s behaviours, such as when people experienced emotional distress. This meant incidents were not always actively investigated to identify lessons learned and drive improvements, which put people at an increased risk of harm. There were also missed opportunities to develop supportive plans of care.

We saw no incident analysis evidence, which meant the service could not monitor themes and trends relating to specific people.

The staff we spoke with described the actions they needed to take following an incident at the service; however, not all staff had followed the protocol.

The provider had an action plan in place, which was set up following its last inspection. This plan failed to address all issues identified at the previous inspection fully, and during this assessment.

However, staff told us they regularly discussed lessons learned with the registered manager, reflecting on what happened during an incident, and whether any changes were required to improve safety, for example.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed and monitored. The registered manager confirmed the people living in the home had lived there for a while. However, they said they would work with people, their relatives, and the new provider, if a person opted to move out of the service, ensuring continuity of care.

Systems were established to ensure that staff supported people if they needed to go to the hospital. People had an ‘emergency admission pack’ containing key information about how best to support an individual. This record is designed to go with an individual when transferred into a hospital or another care facility.

However, the records we reviewed required updating. For example, it stated within one admission pack that the person did not have a Deprivation of Liberty Safeguards (DoLS) in place, and that they required the use of a plastic plate guard. This information was incorrect.

The service did not have effective safeguarding systems to help protect people from abuse.

Safeguarding concerns were not always identified or reported to the appropriate organisations. For example, during our review of daily notes, we found details of an incident involving a person living at the service. In the communication book, on the same date, there was a description of a bedroom fire door becoming damaged during an incident related to the same person. However, it was unclear whether this incident met the threshold for a safeguarding referral, as there was no formal record of this incident. This incident had not been reported to CQC as required.

However, staff had received safeguarding training and understood how to recognise abuse and report concerns. The registered manager had appropriately applied to the local authority for DoLS authorisations for people. This meant people were subjected to some restrictions in their lives, which were recorded in their DoLS.

Following our feedback, the provider informed us they had implemented new safeguarding processes, including frequent team huddles, governance meetings with all staff, and an oversight record of all incidents, accidents, and safeguarding concerns.

The provider did not always work well with people to understand and manage risks, and risks to people were not always assessed or reduced.

During our first visit, we observed several environmental and infection prevention and control (IPC) risks, which staff did not always notice until we brought them to their attention. (See the safe environment and IPC sections for more details).

The personal emergency evacuation plans (PEEP) for two people did not provide clear and robust information to ensure that staff and emergency services understood how to provide safe and effective care. Assessment gaps existed in areas such as supporting people with potential choking episodes, sensory, mobility, ‘going on holiday,’ and swimming. This meant there was no information to guide staff in supporting people in these areas. However, some of these records were provided upon request.

Behavioural incidents were not always recorded on the provider’s internal systems; when they were recorded, they did not always include full details. For example, when behavioural incidents led to skin damage, information relating to the type and status of the wound was missing.

Staff advised us that care records did not always reflect the people living at the service and, on occasions, must be returned to the staff member who implemented them for amendments to be made.

However, some risks to people were assessed and reduced. For example, when communicating with people, we saw a person supported in line with their risk assessment. Staff described how they supported people with individual risks, such as when they are in pain, or when people require some time alone for sensory stimulation.

The service had a positive approach to risk-taking. Staff told us, “We take some of our residents to Church every Sunday, and we will sit in the background to promote their independence.”

The provider did not detect and control potential risks in the care environment or ensure that facilities supported the delivery of safe care.

We found concerns with the safety of the home environment that may have negatively affected people’s experience of living at the service. For example, we identified broken furniture in people’s bedrooms that required repair.

During the assessment, we saw several environmental concerns that posed a risk to people. For example, people were at risk of harm because free-standing wardrobes were not secured to walls. We found that fire doors did not always work correctly. For example, an excessive gap was above one of the fire doors. Another fire door with a broken door closure had been temporarily fixed, but remained a risk to the people, as live wires were hanging from the closure. This placed people at risk, as the fire doors would not work effectively in a fire. Several boxes of archived records were stored within a garden shed, presenting a significant fire hazard. The fire alarm testing panel was not being checked weekly.

We identified several safety risks. A portable fan was observed with no protective cover attached, and window restrictors were missing, posing a risk of falls from height. The fence in the back garden needed repair, which was a potential safety risk for people using the garden. Staff had not consistently checked the fridge/freezer and food temperatures, therefore, they did not identify any potential food hazards. We found out-of-date food past its ‘best before end (BBE)’ date. Cereals had been decanted into containers, but there was no record of ‘use by’ or ‘best before’ dates as per national guidance.

The registered manager told us they had submitted an improvement proposal to the provider to redecorate people’s bedrooms and refurbish the kitchen. However, when our assessment concluded, this proposal was not authorised.

Following our assessment feedback, the provider promptly replaced the broken furniture in people's bedrooms. The provider also ensure that all environmental safety concerns that posed a risk to people were rectified, including securing freestanding wardrobes, repairing a fire door closure, installing window restrictors, and removing archived files. The provider also confirmed that they immediately address the concerns relating to the 'best before end (BBE)' dates.

The provider did not always make sure there were enough qualified, skilled and experienced staff.

The registered manager had not always ensured safe recruitment practices were followed, and gaps in staff work history had not always been explored. The provider addressed these concerns in response to our findings.

While we observed enough staff to keep people safe within the home, there was often limited time for staff to spend with people individually in the community to keep them safe. The staff we spoke with did not always feel that enough staff were deployed to support people's daily access to the local community. Staff told us, “We are stretched, we don’t go out every day, we will often organise indoor activities,” and “Residents all do the same activities. Wednesday is Club Day, so everyone goes to the club. Swimming is another day, so everyone goes swimming. Some people don’t get to choose their activities.”

The registered manager had no oversight of staff training, and not all staff had completed essential training to provide safe and effective care.

Not all ‘relief’ staff (employed at a sister home) who work alone at the service have completed fire marshal or medicine training. Other permanent staff had not completed fire marshal training or first aid at work training. Although some staff had recently completed nutrition and hydration training, it had not been completed by all staff, despite this being relevant for one person who is supported by the Speech and Language Therapy Team (SALT).

Checks to assess staff competency in administering medicines were either not completed or not completed in a timely manner. Therefore, the registered manager could not be assured whether learning had been applied or whether staff required additional learning. National guidance recommends that all staff administering epilepsy medication have an annual review of the knowledge, skills, and competencies relating to managing and administering medication. Furthermore, staff had not received a dysphagia competency assessment, despite the March 2025 dining and nutrition quality walkaround record stating they had completed this.

However, staff told us they received regular supervision and attended regular team meetings.

Following our assessment feedback, the provider arranged for all staff who administer medication to undergo a competency check to ensure they have the knowledge and skills to safely and correctly handle and administer medicines. Several staff members have now completed dysphagia training, but not all have.

The provider did not always assess or manage the risk of infection.

Although people, relatives and professionals did not raise concerns about the home’s cleanliness, our on-site assessment identified several environmental infection, prevention, and control (IPC) concerns. For example, we saw a ripped high-back chair in a person’s bedroom. The records we reviewed described a covering on the chair; however, this cover was not in place during our assessment.

In another bedroom, we found multiple IPC concerns. This included severe dampness and mould throughout the whole ensuite, making the room smell ‘musty.’ This was due to inadequate ventilation. Good infection control practices, such as an unclean toilet brush and a rusty pedal bin with no liner, were not followed. The en-suite radiator had rusted. We observed unclean personal items such as a broken hairbrush and an old bar of soap placed directly next to a person’s toothbrush; these were stored on a painted windowsill, where the paint was flaking, which meant the wood beneath was exposed. Wood is porous and cannot be thoroughly cleaned, as liquids may seep into the woodwork. We found urine splashed over the toilet and significant stains under the toilet pan. Limescale was found on the pipework and shower hose in multiple shower facilities. There was mould on a shower curtain in another en-suite shower room. The extractor fan in the communal bathroom had not been cleaned. Cleaning logs were reviewed as part of our review, and we found that not all staff recorded their cleaning duties.

This increased the risk of infection not being prevented or controlled.

Staff took immediate action during our onsite visit and deep-cleaned the en-suite bathroom. The registered manager finally ordered a new chair to replace the damaged one.

However, staff supported and encouraged people to keep their rooms clean and tidy. Staff confirmed they had completed IPC training, could describe scenarios when they were required to use personal protective equipment (PPE), and knew infection outbreaks needed to be reported to management.

People received their medicines as prescribed. The service had some systems and processes in place to enable the safe and effective use of medicines. However, where people were prescribed ‘when required’ (PRN) medicines for managing pain and constipation, PRN protocols lacked detail. Where people were prescribed variable doses of a PRN medicine, there was no guidance about when to use the lower and higher doses. Furthermore, guidance for staff on how people communicate that they need medication required improvement. Where people are prescribed PRN medicines for managing seizures, PRN protocols do not specify which seizure the medicine is to be used for. It did not include guidance on what staff must monitor following medicine administration. Furthermore, there were no instructions on when a second dose can be given, including whether this needs to be authorised by ambulance staff or a GP, or whether a clinician has granted written authorisation. During our assessment, the service was recommended to store additional seizure medication as a safety precaution.

Not all staff had received appropriate training to support people with their medicines, and annual competencies had not been completed for all staff who administer medication. Audits of medication did not identify the concerns we found during our assessment.

However, medicines were stored safely in the home, and the service supported people in receiving their medicines safely away from the service. Following our assessment, the service acted and arranged for people’s GPs to provide detailed guidance regarding ‘when required’ medicines. Information relating to how people communicate when they are unwell has been reviewed and updated, and staff’s medication competencies were assessed.