CQC report explained · a residential care home
What the CQC found at Greenbanks Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, July 2023
Greenbanks Care Home was rated Inadequate and placed in special measures; inspectors found serious safety, management and dignity problems.
The inspection was unannounced and took place over 22 and 23 May 2023. Inspectors spoke with people, relatives and staff. They reviewed care plans, medicines records, risk assessments, recruitment files, training records and the home’s management systems.
The home was not safe. Fire doors, windows, hot radiators, medicines, infection control and some care records were not managed properly. Inspectors also found risks around choking, burns, falls and people’s health conditions. Staff recruitment checks were not always complete.
The home had made some improvements in staff training and mental capacity work. However, many problems from the February 2023 inspection had not been fixed or kept improved. The overall rating changed from Requires Improvement to Inadequate, and the home was placed in special measures.
Access to healthcare
People had access to regular healthcare services and were supported to attend appointments relating to their health conditions.
“People had access to regular healthcare services such as GPs, opticians, and chiropodists, and were supported to attend regular appointments in relation to their health conditions.” from the report
Some personalised bedrooms
People’s bedrooms were furnished and adapted to reflect their needs and preferences, with evidence that people or relatives had helped choose the furnishings.
“People's bedrooms were furnished and adapted to meet their individual needs and preferences.” from the report
Some positive relationships
Several people and relatives said staff were kind, caring and made time for residents, although inspectors also found undignified care in practice.
“The whole team are kind and caring and make time for each resident.” from the report
Improved mental capacity work
The provider was no longer in breach of the regulation about consent to care and treatment. Some records still needed to be completed and reviewed.
“Enough improvement had been made at this inspection and the provider was no longer in breach of Regulation 11.” from the report
Fire and premises safety
seriousFifteen fire doors were not effective. Other premises risks included broken or missing window restrictors, accessible cleaning products and radiators hot enough to cause burns.
“Fifteen fire doors throughout the home were not effective.” from the report
Medicines management
seriousMedicine records were inaccurate or inconsistent. Some medicines, including controlled drugs and time-sensitive medicines, were not always managed as intended.
“People's medicines were not being properly and safely managed. This placed people at risk of harm.” from the report
Infection control
seriousThe home was not always clean, cleaning records were incomplete, and inspectors saw risks of cross-contamination and poor hand hygiene.
“The provider had failed to ensure that systems to prevent and control infection were implemented effectively.” from the report
Dignity and privacy
seriousInspectors saw people being assisted in ways that did not promote dignity or choice. Treatment was also carried out in a public area without privacy screens or an offer of a private room.
“The failure to ensure people's privacy and treat them with dignity and respect was a breach of Regulation 10(1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Weak management oversight
seriousAudits and care plan checks did not identify continuing safety and record-keeping problems. The provider had also failed to maintain complete and up-to-date records.
“The provider's governance system was ineffective in identifying where fundamental standards were not being met or driving improvements where required.” from the report
Recruitment checks
seriousOne staff file did not show an enhanced DBS check or satisfactory evidence of relevant previous conduct. Two files had unexplained gaps in employment history.
“This put people at risk of not being supported safely.” from the report
- 01What immediate action has been taken to make all fire doors, window restrictors and radiators safe?
- 02How are medicines, including controlled drugs and time-sensitive medicines, now checked and recorded?
- 03How will you make sure care plans and dietary information are complete, consistent and updated when people’s needs change?
- 04How will people receive private treatment and care that consistently protects their dignity and choice?
- 05What personalised activities are now available for people who spend time in bed, live with dementia or have limiting health conditions?
This was an unannounced comprehensive follow-up inspection covering all five key questions, including infection prevention and control. This explanation was written from the published report of 14 July 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, March 2023
Rated Requires Improvement, with Safe rated Inadequate; inspectors found serious problems with medicines, infection control, risks, staffing checks and oversight.
This was an unannounced focused inspection. Inspectors visited on 9, 10 and 21 February 2023. They spoke with people, a relative, staff and a visiting health professional. They also checked care plans, medicines records, recruitment files, training records, audits and other records.
Inspectors found that medicines were not managed safely. There were missed and late doses, inaccurate records and medicines given by staff who had not been trained. They also found poor infection control during a Covid outbreak, unsafe premises risks and incomplete systems for identifying and managing risks.
The home did not always follow the law when making decisions about bed rails, sensor mats and CCTV. Staff training and recruitment checks were incomplete. Care plans and assessments were not always accurate or complete, and quality checks did not find or correct these problems.
The overall rating fell from Good at the previous full inspection in 2019 to Requires Improvement. Safe was rated Inadequate, while Effective and Well-led were rated Requires Improvement. Caring and Responsive were not inspected during this visit, so their earlier ratings were carried forward.
People felt safe
People told inspectors they felt safe and were happy. Some people also said staff were kind and usually available.
“People stated they felt safe and that they were happy.” from the report
Support from health services
People had access to healthcare services and the home worked with professionals such as GPs, district nurses and opticians.
“There was evidence of working with other agencies such as district nurses and chiropodist.” from the report
Meals and choice
People said they enjoyed the food and were offered a good variety of choices. The menu had been developed with input from people living in the home.
“People were supported to eat and drink enough to maintain a balanced diet.” from the report
Friendly staff
Inspectors found staff to be friendly and motivated. Feedback from people and a relative was positive about the staff.
“Staff were friendly and seemed motivated in their roles.” from the report
Medicines were unsafe
seriousRecords were inaccurate, some medicines were missed or given late, and untrained staff administered medicines. This placed people at risk of harm.
“People's medicines were not being properly and safely managed. This placed people at risk of harm.” from the report
Infection control was poor
seriousDuring a Covid outbreak, staff did not always use the right protective equipment or follow safe procedures. The outbreak had not been reported to the relevant health protection body.
“Infection control within the building was poor considering the home was in outbreak.” from the report
Risks in the building
seriousInspectors found concerns about fire doors, fire detection, windows, hot surfaces and bath water checks. Some risks were still present after they had been recorded as dealt with.
“Risks related to the premises were not always safely managed.” from the report
Training and recruitment
seriousSome staff had not completed required training or updates, including medicines, moving and handling, fire safety and safeguarding. Recruitment checks were also incomplete.
“The failure to ensure staff received appropriate training was a breach of Regulation 18(1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014” from the report
Consent and decision-making
seriousThe home did not always complete decision-specific capacity assessments or best-interest decisions for bed rails, sensor alarms and CCTV. Some consent records were missing.
“The provider did not always ensure that decision specific mental capacity assessments (MCA's) and best interest decisions were carried out in relation to bed rails.” from the report
Weak management checks
needs fixingAudits showed high results but did not reflect the problems found by inspectors. Care records were incomplete, and management systems did not identify or correct the risks.
“Audit systems for identifying, capturing and managing organisational risks and issues were ineffective and did not drive improvement.” from the report
- 01What evidence can you show that all missed, late and incorrectly recorded medicines have been investigated and prevented?
- 02How are you now managing Covid or other infection outbreaks, including staff PPE, cleaning and reporting?
- 03Have all fire doors, fire detection systems, windows, radiators and hot water checks been made safe and independently checked?
- 04Which staff are now trained and assessed as competent to give medicines, and how do you make sure training stays up to date?
- 05How do you now record consent and mental capacity decisions for bed rails, sensor mats and CCTV?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 30 March 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.
Every inspection of Greenbanks Care Home
5 rated inspections over 7 years: the service has slipped, from Good to Inadequate.
- July 2023Inadequatecurrent ratingdown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- March 2023Requires improvementSafe: InadequateEffective: Requires improvementWell-led: Requires improvement
- February 2021Inspected but not ratedSafe: Inspected but not ratedWell-led: Inspected but not rated
- July 2019Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2014
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- July 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 26 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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Most charge £1,020 to £1,260 a week. 23 can care for a couple. 14 years' experience on average.
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