Greenwood Court Care and Nursing Home

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• 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

We reviewed all 8 quality statements under this key question; learning culture; safe systems, pathways and transitions; safeguarding; involving people to manage risk; safe environments; safe and effective staffing; infection prevention and control and medicines optimisation. During our onsite assessment visit, people told us they had to wait when calling for assistance as often staff told them they were 'busy'. We reviewed call bell reports, requested after our visit, which highlighted extremely poor staff response times. People’s medicines were being managed and administered by trained staff whose competencies had been reviewed. However, poor record keeping and ineffective clinical governance systems meant we could not be assured medicines were being safely managed. We found concerns about safety were listened to, investigated, and reported to the relevant authority where required. Lessons were learned when things went wrong and systems were in place to investigate incidents and accidents. However, the lack of effective governance systems and processes meant not all concerns had been identified. Staff meetings, group supervisions and 1:1 supervision were used to share information with staff and improve the quality of the care provided. Safe recruitment processes were followed. Effective infection prevention and control measures were found to be in place.

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.

People felt comfortable to raise concerns should they have any. Comments included, “I am lucky I can complain if I need to, so around the table at mealtimes I am the spokesperson for others,” and “No complaints from me. If I was not happy, I would speak up for myself and say."

The manager told us, “We discuss at every meeting, previous safeguarding. We know accidents happen, it is how we learn from them to prevent further incidents occurring. So, we use a lesson learned approach with staff to demonstrate how we can improve.”

Systems were in place to support staff’s continued development. Observations of practice, supervision and appraisals were completed to ensure staff felt supported and to promote their continued learning. Incidents and accidents were logged, investigations completed, and where appropriate information had been shared with the Local Authority and the CQC. We saw evidence of lessons learned being shared with staff to identify what went wrong and to prevent future re occurrence. Although there was a system in place for learning from accidents and incidents we had some concerns about the effectiveness of the providers clinical governance processes which meant not all incidents would have been highlighted to the manager.

On the day of our assessment visit we observed 2 people being admitted to the service for respite care. On arrival they received a warm and friendly greeting from staff, were shown around the home and taken to their rooms. However, once in their rooms they waited for prolonged periods of time for assistance from staff to unpack and settle into their new surroundings. When 2 members of our inspection team asked staff for assistance, they were told, 'we are busy' and 'we'll come back later.' One relative told us, “[Person] moved in today and I have not seen any staff for ages. I do not want them sitting in their room all day.”

The manager told us, “We complete a pre-assessment within 24 hours and most face-to-face assessments are carried out. We take at least one member of the team with us for possible admissions so at least they will have another familiar face when they arrive.” However, during our on-site assessment visit we observed a person and their relative becoming quite anxious due to the lack of staff engagement to support them to settle in. This was shared with the area manager on the day of our assessment visit.

On the day of our on-site assessment visiting professionals confirmed the service worked collaboratively with them and did not raise any concerns.

Although people’s care and support needs were assessed prior to admission to the service, on the day of our assessment visit there were not enough staff available to support people and meet their needs. People had to wait for a prolonged length of time for their call bells to be answered and new people entering the service were not given the time and care needed to settle them in.

People told us they felt safe living at Greenwood Court Care and Nursing Home. Comments included, “I feel safe here, because I have people around me,” “I feel very safe here,” and “I can sum it up, I am happy living here, staff are very kind and caring to me. If I was not happy, I can speak for myself and would say so.”

Staff received training and understood their responsibilities to safeguard people from harm. Staff gave examples of safeguarding concerns they had raised with the management team and the action taken to address the concerns. They had confidence in the management and office staff and the action they would take if concerns were raised. A staff member told us, “I would report any concerns to the manager, or I would go higher or to CQC.”

People appeared comfortable and relaxed with staff supporting them.

The provider had systems in place to investigate concerns and ensure appropriate action was taken to keep people safe. The manager was knowledgeable about the local safeguarding procedures, undertaking investigations and working with external agencies for the protection of people in their care.

Care plans included assessments which identified potential risks to people and measures for staff to minimise them. A person told us, “I have a private physio therapist who comes in every week to help me get mobile. My frame is always nearby should I want to use it, but I do try to do without it.” A relative told us, “They [staff] do involve me with any risks, as [person] slides in their chair and the slip sheet did not seem to help. We have purchased a new chair with pressure relieving element to it, to try and keep them up and out of bed.”

Staff were aware of potential risks in people's daily lives. They explained people’s current needs and how they wished to be supported. A member of staff told us, “We complete the risk assessments, we have all had training. We do a full handover in the morning to discuss any changes identified in a person’s needs. Any changes we will update them. We involve people with risk, any equipment needed is risk assessed by physios, I would always update and include people and relatives. Some people have a private physio.”

People did not always receive care in accordance with the risk assessments outlined in their care plans and not all risks were correctly recorded. For example, repositioning charts did not always show 2 hourly turns were completed in line with the guidance in people's care plans. A person’s skin integrity care plan had been updated to include information about a moisture lesion with strict 2 hourly repositioning advised. On the day of our on-site assessment visit this was not being adhered to. Records showed gaps longer than the recommended 2 hours, and in 3 instances at 07.30, 10.00 and 12. 00 no repositioning had been recorded. Only personal care and pad checks were recorded as having been undertaken. When we reviewed the previous 2 days repositioning charts, we identified several instances where staff had failed to record/carry out repositioning in line with the recommended guidance. This potentially placed the person’s skin integrity at further risk of deterioration.

Processes were in place to identify risks to people’s everyday lives. However, these assessments were not always adhered to. The documentation for 2 people who required regular repositioning throughout the day/night to protect their skin integrity had not been completed. This meant we could not be assured staff were consistently supporting people in line with the guidance in their risk assessments.

People we spoke with raised no concerns regarding their environment or equipment. They were complimentary of different areas around the home they accessed and where they socialised.

Staff were aware of who to report any faults or issues regarding maintenance of the service or equipment.

People were supported in a safe environment and with access to specialist equipment if required. People had the choice to use the communal areas or quiet areas if they preferred.

There were effective arrangements to monitor the safety and upkeep of the premises. Although on the day of our onsite assessment visit, we found a room used for storing a large amount of equipment unlocked. After our visit, the area manager informed us a keypad lock had been placed on the door to prevent people entering for their safety.

The views of people using the service and others, who had an important part in their lives, were varied. They highlighted there were, on occasions, insufficient staff available to meet people's needs. Comments included, “Some staff come in and have a chat, depends on how busy they are,” “I sometimes ring for someone to come and help me wash but it takes a while for the call bell to be answered, this often happens. They [staff] say we are busy." “They [staff] are kind and caring when you need it but do not have the time to come and talk to you.” “Often if I press my bell, they [staff] take a long time to come to me.” Relatives we spoke with told us, “I come in regularly, there were so many shortages of staff. We were sitting in the lounge with 3 staff on the whole floor. I sent an email 2 weeks ago. I have not received any response,” and “It seems to be weekends mostly. Care staff seemed tired at weekends. Staffing has not seemed so good. Appears to be a shortage of housekeepers so care staff cover this at weekends.”

Staff we spoke with were open and honest about the challenges they faced. They told us staffing levels were improving and becoming more stable. Comments included, “We are fully staffed in the kitchen, but it has taken us 2 years and we were using agency. Several staff recently left but I think it is starting to settle down now,” and “We went through a rough patch, a lot of carers left, we had agency until new carers came in. There seemed to be no limit before but now we are being run properly.” New staff had been recruited to the service. However, they were still in the process of completing their induction and training. It would take some time for them to be truly integrated into the staff team, to get to know people and how they wished their care to be provided.

The feedback on staffing levels was variable. Call bell response times were not monitored. This meant the management team were unaware of the length of time people were waiting for staff to respond to their request for assistance and we could not be assured staff deployment was effectively meeting people’s needs. During the on-site assessment, we observed periods of time where staff were unavailable to support people promptly. Call bells were buzzing for approximately 5 minutes before staff were able to assist the person. People told us they had to wait when calling for assistance as staff told people they were busy. New admissions to the service also shared their concerns with us regarding the lack of staff assistance and support to help them settle into their surroundings. On the day of our assessment visit we observed staff to be task focused and there were not always enough staff available to provide prompt support when needed.

Systems and processes did not demonstrate how the service ensured there were always enough suitably trained and experienced staff to meet people’s needs. Processes were not in place to monitor call bell response times. We reviewed daily call bell reports from 18/07/2024 to 14/08/2024, which highlighted staff response time was poor. Of those we reviewed we were unable to find any call bells which had been responded to in under 5 minutes. A small number of call bells daily were being responded to between 5 and 6 minutes. Following our on-site visit the area manager sent us a list of actions they and the senior management team would be undertaking to address these concerns. Including, implementing a daily call bell monitoring audit, reviewing the daily allocation and deployment of staff across the home, and a weekly review of the dependency tool to ensure staffing hours met people’s needs. They also assured us that, several new staff members were in the process of completing their induction and training. However, at the time of the assessment we were not assured there were enough suitably qualified, skilled, and experienced staff deployed effectively to meet people's needs. Any new processes need time to be embedded into the service and for the management team to demonstrate their sustainability. Safe staff recruitment processes were in place. Including the completion of appropriate pre-employment checks such as references from previous employers and disclosure and barring service checks (DBS). This helps employers make safe recruitment choices.

People’s rooms and communal areas appeared clean and tidy. People told us their rooms were kept clean and tidy and their bedding changed regularly.

Staff had access to personal protective equipment (PPE) and had received training around infection prevention and control. The deputy manager told us they were planning to introduce an infection prevention and control lead.

The home was clean and tidy throughout. People’s bedrooms, communal areas and bathrooms were free of malodorous. Personal protective equipment was readily available for staff. Hand washing was observed when staff carried out people’s medicine administration. We noted in one of the communal bathrooms a toilet brush which appeared unclean. After our onsite assessment visit the area manager advised all toilet brushes had been removed from communal areas, and those in people’s bedrooms are gradually being replaced.

Staff had completed infection prevention and control training and were provided with PPE. The provider had an up-to-date policy in place to support effective infection prevention and control and was following current guidance. Regular audits were undertaken, outlining any actions taken and by whom.

One person told us, “I have just told staff I need some medicine; they [staff] are going to get it for me. When I ask, they [staff] always get it for me to take.”

Staff had received training in administering medicines to people. We observed people receiving their medicines when prescribed on the day of our onsite assessment visit. Time sensitive medicines for example, for people with Parkinsons’ Disease were administered in a timely manner.

The provider did not have effective systems in place to safely manage medication. They had not identified concerns observed on the day of our assessment visit. We found gaps on some people’s MAR charts which the providers auditing process had failed to identify. We saw one incident where the controlled drugs (CD) balance appeared not to be accounted for, we later found out that this was due to inappropriate documentation. Medicine audits we reviewed for July 2024 failed to identify a person’s liquid pain relief needed to be returned within 90 days of opening the bottle, after which it was less effective. The bottle of liquid Oramorph had an opening date of 22/04/2024. This medicine was still in use in the controlled drugs cabinet and had last been administered on the 24/07/2024, 2 days after is 90 day shelf life period, potentially lessening it’s effectiveness for the person. In Iine with the providers medication policy nurses and senor care workers were responsible for administering medication and reviewing the CD book twice a day. We found a person’s, weekly pain relief patch was administered on 10/08/2024, their medicines administration chart (MAR) was correctly signed. However, when reviewing the CD book, we saw another entry for a pain relief patch for the same person on the 12/08/2024. There was no explanation as to why another patch was applied within 48 hours. The transdermal patch application chart had not been completed for the 12/08/2024. The MAR chart had not been amended to reflect their next patch would now be due on the 19/08/2024 instead of the 17/08/2024. The senior management team carried out an investigation into the concerns we raised on the day and advised staff retraining, lessons learned, and staff medicine competencies would be undertaken.