What the CQC found at Goodwins Hall Care Home

The people inspectors spoke with said they felt safe and well cared for. They could describe improvements made after the serious incident.

“People we spoke with told us they felt safe and well cared for living at the service.” from the report

The home updated care plans and risk assessments, sought specialist advice and put support in place for people and staff affected by the incident.

“In response to the serious incident, the provider was able to demonstrate actions taken to reduce the risk of reoccurrence, including updates to people's care plans and risk assessments.” from the report

Inspectors found safety equipment checks, health and safety audits, fire drills and evacuation practices. The home was also operating with more staff than its assessed minimum.

“Maintenance checks of safety equipment were in place, and the care provider also completed their own health and safety audits of the service.” from the report

Staff and people who witnessed the incident had access to additional training, support and external counselling.

“The provider had implemented additional training for staff, and support mechanisms to ensure staff and people who witnessed the incident had access to specialist services such as external counselling following this incident.” from the report

Some people had smoking risk assessments and emergency evacuation plans, but did not have individual fire risk assessments despite previous fire safety concerns. The home was updating its recording systems.

“People had individual smoking risk assessments and Personal Emergency Evacuation Plans (PEEP) in place, but not individual fire risk assessments, where previous fire safety concerns had been identified.” from the report

Fire risks linked to emollient creams were not recorded in care records or on every person's emergency evacuation plan. Inspectors asked for records to be updated.

“Where people required use of emollients and creams to care for their skin, associated fire risks had not been reflected in their care records prior to this incident, and had not been reflected on each person's PEEPS, only for those who smoked.” from the report

Some smoking areas needed suitable ashtrays and clearer signs. Staff were also smoking in other outside areas without the required safety measures, and the home's own checks had not identified this.

“Additional outside areas were being used by staff to smoke, without the required safety measures in place.” from the report

Where people neglected their hygiene or declined regular laundering of clothes, the home needed to review the risks with other professionals and consider mental capacity and best-interest decisions.

“Greater consideration was required where people were known to be at risk of neglecting their personal hygiene or declining to have their clothing regularly laundered.” from the report