The Gardens Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. The service was in breach of legal regulation in relation to the governance of the service, particularly relating to medicines management.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People and relatives did not specifically comment on the learning culture in the home. However, people were at risk of receiving care that did not reflect their needs and wishes, as systems for identifying and sharing learning needed improving.

Staff did not specifically comment on the learning culture. However, the provider was unable to demonstrate how lessons were learnt and shared with staff.

The provider did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice. The provider was unable to provide an incidents and accident log to demonstrate how incidents had been dealt with. They were also unable to provide examples of recent safeguarding investigations.

People and relatives did not specifically comment on their transition into the home.

Staff confirmed information is shared between different partners to help ensure people receive the correct care. A staff member commented, “People receive assessments from physiotherapists and occupational therapists as necessary.”

We did not receive any feedback from partners.

The provider worked with people and healthcare partners to establish and maintain safe systems of care. Various assessments had been completed both before and after people moved into the home. These were used to develop people’s care plans. The assessments included gathering information about people’s life history and any particular preferences they had, which staff should be aware of.

People and relatives gave positive feedback about feeling safe. A person said, “I feel safe here as there is always someone to look after you.” A relative commented, “I’ve no issues at all at the moment. I’m happy [family member] is safe here.” However, the shortfalls we found during the assessment impacted on the quality and safety of people’s care.

Staff confirmed they knew how to identify and report safeguarding concerns, and felt confident to do so. A staff member said, “I've completed safeguarding training, that was all done online. I know the right way to report any concerns and I wouldn't hesitate to do so.” However, the provider confirmed to us they could not provide examples of recent safeguarding investigations to demonstrate the action they had taken to understand safeguarding events and ensure people’s safety.

Staff were capable and careful when supporting people. They chatted to people and provided reassurance to help promote their wellbeing.

The provider lacked effective systems to demonstrate safeguarding concerns were investigated thoroughly and lessons were learnt. The provider’s safeguarding log lacked detailed information about lessons learnt to prevent situations from happening again.

People did not specifically comment about managing risks. However, the shortfalls we found during our assessment impacted on people’s care.

Although, most staff did not raise any concerns about managing risk, we identified shortfalls which could potentially impact on people’s safety and welfare. This included a lack of clear guidance for staff to support people when they were distressed and a lack of training and support to care for people with complex mental health needs. One staff member said, “Staff haven't had de-escalation training.” This is training to help staff recognise when people are experiencing agitation or distress and how staff should respond to reduce this.

Staff supported people appropriately to help keep them safe. For example, a staff member helped a person with specific needs to feel reassured about their situation and that they were safe.

The provider did not always work well with people to understand and manage risks. They did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Improvements were needed to ensure people were supported appropriately when they were distressed. Positive behaviour support (PBS) care plans and risk assessments lacked person-centred information about triggers and proactive and reactive strategies to support people sensitively. Records for individual incidents lacked relevant information to enable staff to identify learning to help prevent future incidents.

People did not raise any concerns about the environment. A person told us, “My room is nice.” However, we did find some shortfalls with the upkeep of the environment.

Staff gave positive feedback about the environment.

Some areas of the home required some maintenance, such as damaged paintwork in corridors and flooring. Some equipment was also being stored in communal areas and corridors, due to a lack of suitable storage. The manager said they would look at alternative solutions.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Most health and safety checks were up to date. Records showed water temperatures were lower than required. The manager provided assurances this would be addressed.

Most people and relatives commented staffing levels needed improving. A person told us, “There definitely aren’t enough staff, especially at night. There are only 3 care staff and lots of people need 2:1 support.” A relative said, “Sometimes it takes a while for buzzers to be answered.”

Most staff told us staffing levels were not sufficient to meet people’s needs appropriately. A staff member told us, “There used to be more staff, and it is harder now there are less of us on duty.”

We observed positive interaction between people and staff. For example, a person who was waiting for the doctor was laughing and joking with a staff member.

Improvements were needed to ensure new staff were recruited safely. Not all pre-employment checks had been fully completed to ensure staff were suitable to work at the home. Training was overdue for some essential training including face to face moving and handling and first aid training. The provider’s training matrix also indicated some staff had not completed any training.

People gave positive feedback about infection prevention and control (IPC). A person told us, “They keep things nice and clean. My room is cleaned every day.”

A staff member said they were happy with the staff and resources allocated to the domestic team. They commented, “We try to do a deep clean, one room on each corridor every day. There is never any issue with the budget.”

The home was clean and tidy throughout when we visited.

The service assessed and managed the risk of infection. They promptly detected and controlled the risk of it spreading and shared concerns with appropriate agencies. The provider had IPC policies and procedures. Most staff had completed IPC training.

Although people and relatives did not specifically comment on medicines, shortfalls in medicines management impacted on the care provided.

Although staff did not raise any concerns about medicines, we found shortfalls in their management. We discussed our finding with the manager at the time.

Systems to manage medicines were not robust. Medicines records assured oral medicines were being administered as prescribed. The provider lacked a robust process to assure staff administering medicines had up to date competencies. Processes to manage topical medicines were not robust. No topical medicines records were available prior to day of our visit. Therefore, there was no assurance topical medicines were administered as prescribed. Not all staff had access to people’s records resulting in care not being recorded timely. Some care staff informed other staff what to record in people’s care records. Agency nurses did not have access to electronic records, carers entered records with their login but signed by an agency nurse. Records on electronic handheld devices did not match those on the desktop system. For 1 person the handheld device recorded no bowel motion for more than 8 days whereas the desktop system showed 2 days. For 1 person requiring fluid intake monitoring, records showed only 1 or 2 drinks on some days. Electronic and paper records were used but did not match. Processes for recording thickener varied. In 1 area of the home staff were using paper and electronic systems intermittently. Drinks were administered without the correct amount of thickener documented on both electronic and paper systems. In another area of the home there were no thickener administration records. When required protocols needed improving as they lacked personalised information. The effects of the when required medicines were not recorded, which not in line with guidance or the homes’ policy. A person received medicines covertly, medicines which are disguised in food/drink following, without supporting documentation. The provider did not have a process for recording when someone with fluctuating capacity (can sometimes accept their medicines but at other times does not have understanding around this) received their medicines covertly. Medicines were stored safely and securely.