Archived: Goldcrest

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We identified 2 breaches of the legal regulations. Systems were either not in place or robust enough to demonstrate the quality and safety of services was effectively managed. The provider had not ensured the service could sustain improvements and this has led to a deterioration of the service. People had been harmed and placed at risk of harm. The registered manager and provider failed to notify CQC of 13 notifiable incidents which may have resulted in harm for the people using the service. We received feedback from healthcare professionals who felt the registered manager was not always proactive however people, relatives and healthcare professionals felt the registered manager was kind and caring.

This service scored 39 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The registered manager told us they had been in post as the manager for Goldcrest since our last inspection in October 2022 and had applied to be the registered manager on 10 July 2023. As part of their application, the registered manager told CQC they would complete their Diploma Level 5 in qualification in leadership for health and social care by March 2024. On the first day of our inspection the registered manager told inspectors they had not been able to complete their diploma because they had not had time to do this. This was because the registered manager had needed to cover kitchen and care shifts due to staff sickness and annual leave. The registered manager told us they understood their roles and responsibilities as a registered manager, but they were still learning and told us, “I don’t know what I don’t know.” We received mixed feedback from staff. Staff felt the registered manager still had a lot to learn and did not always have support from the provider to do their job well. We received comments such as, “[registered manager] is new to it, has a lot to learn and doesn’t have enough support” and, “things have got worse.” However, staff did tell us the registered manager was kind and caring. One staff member said, “[registered manager] is absolutely as good a carer than anyone in Goldcrest. She understands every resident in Goldcrest.”

There was not a process in place to support the registered manager to learn and develop into their role. This meant the provider could not be assured the registered manager had been provided with all the information, guidance and best practice they needed to meet the requirements of their role, and this had placed people at risk of harm.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The registered manager told us they felt supported by the provider, however, did not always feel empowered to manage the service. During the inspection the registered manager told us, “In some ways I have been over supported by the provider, I have realised I haven’t been doing a lot of the things I should be doing.” This had led to significant shortfalls and people had either been harmed or put at risk of harm.

Systems and processes were either not in place, or effective, at identifying areas of improvement we found throughout this inspection. This meant quality performance had not always been assessed, potential risks to people not always identified and lessons learned to drive improvements had not always been possible. People had been placed at risk of significant harm. At our inspection in July 2022 the provider told us they would make necessary changes to comply with Health and Social Care regulations to ensure people received safe quality care. During this assessment of the service we found any improvements made by our inspection in February 2023 had not been sustained and the home had deteriorated leading to breaches of regulation and people being harmed or put at risk of harm. The provider failed to have robust systems in place to identify when care was not being provided and people had been harmed. We reviewed the care records for a person who had been assessed as requiring support from staff to reposition 3 hourly during the day and 4 hourly at night to reduce the likelihood of skin breakdown. The person’s care records showed gaps in between repositioning for as long as up to 9 hours. This had not been identified by the registered manager or provider and the person’s skin began to deteriorate. The registered manager and provider told us they reviewed accidents and incidents however, had failed to identify 13 incidents that were reportable to CQC. This meant external scrutiny was not possible to ensure people were safe. People had been placed at risk of harm.

We found staff had not always identified when people had needed a healthcare professional, and their health had deteriorated as a result meaning people had been harmed or placed at risk of harm. However, relatives told us healthcare professionals were requested appropriately when their loved one needed them. Comments included, “yes they have called in these people in when needed” and, “yes, they can always contact the doctor.”

The registered manager told us they could access healthcare professionals when they were needed.

Healthcare professionals raised concerns that their advice was not always listen to, requested information to make decisions about people’s care and treatment was not always made available and the registered manager was not always aware of partnerships and communities they could refer people to or know where to go for help. Comments included, “Staff appear to listen to advice etc but do not always follow through with it” , “I was surprised when asking for evidence, care plans and documentation that most of it seemed out of date or it couldn’t be found immediately” and, “The manager did not appear to know what external support services were available or where to go for help.”

The provider had not established a process to ensure staff and leaders engaged with people, communities and partners to share learning and ensure continuous improvements to the service. We asked the registered manager told us they were part of a network of registered managers group on social media to aid their continued learning. However, was not able to provide us with any examples for us to assess if this was effective.

The registered manager told us a lessons learned process was in place to reflect when things went wrong. We asked to review any documents that demonstrated how the system worked however, staff were unable to locate any documents and we were not provided with the records. Following our inspection the provider sent us an example of a lessons learned process from an incident in February 2024. We were unable to assess the effectiveness and sustainability of the lessons learned process as regular use of the lessons learned form had not been embedded. For example, the registered manager had been informed of a medicines error in January 2024 by a healthcare professional. No lessons learned paperwork had been completed to demonstrate learning and actions taken to minimise a future occurrence. This meant the provider could not be assured lessons were learned to mitigate a risk of incidents from happening again and this had placed people at risk of harm.

System and processes were either not in place, or effective, at identifying areas of improvement we found throughout this inspection. This meant quality performance had not always been assessed, potential risks to people not always identified and lessons learned to drive improvements had not always been possible. People had been placed at risk of significant harm. After our inspection on 23 September 2022 CQC imposed conditions to the registered providers registration. One of these conditions required the registered provider to devise and implement a system to review, audit, analyse and show learning from accident, incidents and safeguarding. Care plans and care records. Capacity and decision making. Medicine administration and management and Staff recruitment files. During our assessment of the home from 7 February 2024 to 27 March 2024, the provider was unable to demonstrate they had met this condition of their registration. We identified shortfalls relating to audits, care records, capacity and decision making, safe medicine administration and staff recruitment records leading to breaches of regulations. The provider had failed to learn from our previous inspections and had not improved the home. This had placed people at risk of significant harm.