CQC report explained · a residential care home
What the CQC found at Garson House Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- People were protected by improved risk assessments, safety checks, staffing and infection control. Medicines were given when needed, but medicines records, as-required medicine protocols and medicines audits still needed improvement.
- Effective?
- Requires improvement
- This key question was not rated in this inspection. The report says the home worked well with health professionals and had improved its approach to capacity assessments and best-interest decisions.
- Caring?
- Good
- This key question was not rated in this inspection. People told inspectors they felt safe and were looked after well.
- Responsive?
- Requires improvement
- This key question was not rated in this inspection. Communication had led to changes in activities and menu choices, and people could see visitors without restrictions.
- Well-led?
- Requires improvement
- Management and auditing had improved, but the new governance systems were still being embedded. Medicines auditing was inaccurate and had not identified the issues inspectors found.
What inspectors found, May 2023
Rated Requires Improvement; inspectors found major progress since the previous Inadequate rating, but medicines checks and new management systems were not yet fully reliable.
This was an unannounced follow-up inspection on 18 April 2023. One inspector spoke with people and staff, observed care, reviewed care and medicines records, checked safety arrangements and received feedback from a healthcare professional.
The home had improved since the previous inspection. Care records now reflected people's needs more accurately, staff recruitment was safer, staffing levels were sufficient, the environment was cleaner and safety checks had improved. People told inspectors they felt safe and received their medicines when needed.
Some work was still unfinished. Medicines audits had not found minor problems, including missing as-required medicine protocols and one missing photograph on a medicines record. The new care planning, incident review and governance systems were still being embedded. The home was no longer in Special Measures and the previous breaches had been resolved, but conditions on the provider's registration remained.
More accurate care records
The new electronic care planning system helped staff record and review people's current needs and risks.
“The risk of people receiving unsafe or inappropriate care had been reduced through records now reflecting people's current care needs.” from the report
Improved building safety
Environmental monitoring had improved. Checks covered electrical equipment, fire systems, water temperatures and mobility equipment.
“Environmental safety monitoring had significantly improved.” from the report
Enough staff
Inspectors found enough staff to meet people's needs, and call bells were answered promptly. New recruitment had reduced pressure on the service.
“There were sufficient staff on duty to meet people's needs.” from the report
Better risk monitoring
The home had introduced systems to review accidents and incidents and look for patterns that could lead to further harm.
“The service manager had introduced systems and processes that ensured accidents and incidents were monitored to identify any patterns or trends.” from the report
Improved legal safeguards
Records about mental capacity, best-interest decisions and lasting powers of attorney had improved after the home sought local authority advice.
“We saw records and other supporting documentation was significantly improved since our last inspection.” from the report
Medicines checks missed problems
needs fixingThe medicines audit did not identify issues found by inspectors. Some as-required medicines lacked protocols, and one person's medicines record had no photograph.
“Medicines management audits were completed monthly by a dedicated member of staff; however, they were still being embedded and were not fully effective as they had not identified the minor issues we found.” from the report
New systems not fully established
needs fixingCare planning, incident reviews and wider governance arrangements were new and still being embedded. This meant their effectiveness had not yet been fully demonstrated.
“It was evident more time was needed to ensure an effective governance system was fully embedded to ensure people were safe.” from the report
No formal feedback systems
minorThere were no formal systems to seek ongoing feedback from people, families and staff, although inspectors considered the frequent communication suitable for the home's size.
“Whilst there were no formal systems currently in operation to seek continuous feedback from people, their families and staff, communication was frequent.” from the report
- 01What checks now make sure every as-required medicine has a clear protocol?
- 02How do you check that medicines records, including photographs, are complete and accurate?
- 03Who reviews the medicines audit, and what action is taken when it finds a problem?
- 04How do you know the new electronic care planning and incident review systems are working consistently?
- 05What registration conditions are still in place, and how are you reporting progress to CQC?
This was an unannounced follow-up inspection focused on Safe and Well-led, including infection prevention and control; the other key question ratings were not given in this report. This explanation was written from the published report of 4 May 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, November 2022
Garson House Care Home was rated Inadequate and placed in special measures; inspectors found serious safety and management failings despite kind care.
The inspection was unannounced and took place on 6 September 2022. One inspector spoke with people, relatives, staff and healthcare professionals, observed care and checked care records, medicines, recruitment files, safety checks and quality records.
Inspectors found serious problems with safety and management. Care plans and risk records were often out of date. Some equipment had not been serviced, fire safety checks were not current, incidents were not properly reviewed and one staff member had not been recruited with all required checks.
People were treated with kindness and respect. Medicines were managed safely, infection control arrangements were satisfactory and families could visit. However, the home did not consistently record people's current needs, end of life wishes or meaningful activities.
The overall rating changed from Good at the previous inspection in 2017 to Inadequate. The home was placed in special measures, meaning CQC will keep it under review and normally re-inspect within six months.
Kind and respectful care
People and relatives described staff positively. Inspectors saw staff offering choices and treating people with dignity.
“People received care from staff who had developed positive and caring relationships with them.” from the report
Medicines
Inspectors found effective systems for ordering, storing, administering and returning medicines. Medicine records were completed accurately.
“Medicine systems were safe, and people were receiving their medicines as prescribed.” from the report
Family visiting
People were supported to receive visitors in line with government guidance. Families said they felt welcome and could visit safely.
“People's families told us they were supported to visit in a safe way and felt welcome when visiting.” from the report
Healthcare links
The home worked with external healthcare professionals. The feedback received from those professionals was positive.
“All of the feedback we received from healthcare professionals about the service was very positive.” from the report
Outdated care and risk records
seriousCare records did not always show people's current needs or the care that had been provided. This included missed weighing, missing repositioning records and old emergency evacuation plans.
“People were at risk of receiving unsafe or inappropriate care as care records did not always reflect their current needs and safety monitoring was not always completed.” from the report
Environmental safety
seriousMobility equipment had not been serviced for more than two years. Fire risk, emergency lighting and electrical safety records were also not current or could not be found.
“hoists and other mobility equipment in the service had not been serviced since March 2019 presenting a risk to people.” from the report
Incidents were not reviewed
seriousThere was no formal system to look for patterns in accidents and incidents or to make preventative changes. Inspectors found examples involving a fracture and repeated falls.
“There was no formal system to ensure accidents and incidents were monitored by the service management to identify any patterns or trends.” from the report
Weak management oversight
seriousAudits did not reliably identify problems with care records, equipment, infection control, incidents or recruitment. The provider also failed to notify CQC fully about deaths and a serious injury.
“There were no effective systems to monitor the health, safety and welfare of people at the service and the service environment.” from the report
Limited activities
needs fixingStaffing pressures meant there was no structured activities programme. People sometimes had little to do.
“People had limited opportunity to be involved in activities.” from the report
End of life planning
needs fixingRecords did not consistently document people's end of life wishes. Some plans were blank or missing.
“care and planning to support people at the end of their lives was not always recorded to evidence people's preferences and wishes.” from the report
- 01Which care plans and risk assessments have been updated, and how do you check that they reflect each person's current needs?
- 02Have all hoists, mobility equipment, emergency lighting and electrical appliances now been serviced or tested, and can you show the records?
- 03How are accidents, falls and other incidents now reviewed, and what changes have been made to prevent them happening again?
- 04What action has been taken to improve Mental Capacity Act and Deprivation of Liberty Safeguards practice?
- 05What structured activities and end of life planning are now available for people living in the home?
This was an unannounced inspection that assessed all five key questions and also examined infection prevention and control arrangements. This explanation was written from the published report of 3 November 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Garson House Care Home
4 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- May 2023Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- November 2022Inadequatedown from GoodSafe: InadequateWell-led: Inadequate
- October 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2013
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 14 January 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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17 live-in carers within about an hour of Devon
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £1,020 to £1,270 a week. 15 can care for a couple. 13 years' experience on average.
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Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.