Greenacres Care Home

“The provider was in breach of the legal regulations relating to safe care and treatment, consent and good governance.”

“The service delivered caring day-to-day support, but there were significant weaknesses across safety, leadership and governance that affected the overall quality and reliability of care. Although individual staff were compassionate, the systems needed to ensure safe, consistent and well managed care were not embedded or sustained.”

“Risks around the environment, infection control, medicines and supporting people’s rights were not consistently identified or addressed. Mental capacity assessments were missing when restrictive practices were used, meaning people’s rights were not always protected. Medicines management systems were unsafe: medicines profile sheets were missing, controlled drugs were poorly recorded, guidance for staff on how and when to administer medicines prescribed to be taken as required, such as painkillers were inaccessible. The level of stock in the medicine’s fridge was excessive and increased the risk of stock being out of date. Although there was no evidence of missed doses, these issues created potential avoidable risk. Environmental risks had not been fully addressed, and infection control arrangements were weakened by outdated policies, incomplete training, and lack of clear cleaning schedules. Staffing systems were also ineffective: training gaps were significant, supervisions were not consistently completed and the dependency tool did not evidence how staffing levels matched people’s needs.”

“Governance and oversight systems were not effective. Audits failed to identify obvious concerns, action plans lacked timescales, and there was limited provider‑level monitoring. Some basic safety processes that had previously existed, such as medicines profile pages and routine mental capacity assessments had not been sustained. This indicated a lack of continuous learning, improvement or modernisation.”

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