Archived: Goldcrest

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We identified 1 breach of the legal regulations. Consent had not always been sought in line with the Mental Capacity Act 2005. Restrictive practices such as alarm mats were situated in rooms without consent or Mental Capacity Assessment and best interest decisions. Mental capacity assessments were generic and not decision specific, this is not in line with the Mental Capacity Act 2005. Care was not provided in accordance with best practice guidance. Care plans did not contain all the information staff needed to ensure they met the persons needs and wishes. Staff did not always work effectively across teams and services to support people. Important information had not always been shared with new care services and systems were not robust to ensure staff were aware of any important information they needed to ensure people’s needs were met. People’s care and treatments needs were not always routinely monitored, and this meant some people had received poor outcomes.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Assessing needs during this assessment. The score for this quality statement is based on the previous rating for Effective.

We observed people eating their lunch. People appeared to be enjoying their food and staff encouraged people to eat when needed. Relatives told us their loved one’s enjoyed the food, but some had concerns people were gaining too much weight and they were not sure what had been done about this. We received comments such as, “[person] enjoys their food but is very overweight, I am not sure what is being done about it” , “[Person] seems to like her food” and, “they will bring her sandwiches, [person] has put on weight but then she doesn’t move around.”

The registered manager told us they referred people to the speech and language therapist when they were concerned people may be at risk of choking. The registered manager told us they weighed people every month and compared that weight with the previous month. If people had gained or lost a significant amount of weight this was reported to the appropriate healthcare professionals. A healthcare professional told us, “Weight loss is usually reported to me.”

We found a lack of robust systems and processes to ensure people received evidence-based care and treatment. Staff had not always received up to date training and guidance. Governance systems had not been robust to identify the shortfalls we identified during our inspection. Care plans did not always provide staff with people’s likes and dislikes preferences. This meant staff had not been given full instructions to support people to eat and drink what they wanted, when they wanted. The provider and registered manager did not always use an evidence-based approach such as a tool to monitor people’s weight over a period of time. By only comparing the person’s weight to the previous month, people were at risk of having steady weight loss or weight gain missed and this put people at risk of harm. We shared these concerns with the registered provider who showed us a person's care records who had been assessed using a recognised tool. The person's care plan stated, "[Person's] weight is being monitored weekly." However, no records were provided during or following our inspection to demonstrate these actions had been followed. The provider did not show us any documents to show people's weight had been monitored as part of an ongoing governance audit, this meant the shortfall relating to the person not being weighed had not been identified and had placed them at risk of harm. When people had been assessed by the speech and language therapist team, assessments had been shared with the kitchen staff and food had been made to the correct consistency to prevent the person from choking.

One person had left the care of Goldcrest to move into a new care home. We received feedback from the new care home that Goldcrest had not shared important information about the person. This meant the new care home was not provided with all the information they needed to ensure the persons care and treatment needs met and this had put the person at risk of harm.

The registered manager told us they did not conduct regular meetings as they shared information in daily handover meetings and with encrypted electronic messages. Staff told us they were not always provided with the information they needed to ensure people’s care needs were met. One staff member said, “The management is really bad at passing on any important information, for example when someone is unwell.”

We received feedback from 4 healthcare professionals who told us whilst the registered manager cared for people, staff did not always follow medical advice, did not always show understanding and needed better training to support people. Healthcare professionals raised their concerns around poor record keeping and were concerned about the safety of people living in the home. We received comments such as, “It is evident that the home manager cares about her residents and wants the best for them, but perhaps at times is unsure on how best to achieve their best outcomes and is not always pro-active in implementing positive changes without support” , “I was surprised when asking for evidence, care plans and documentation that most of it seemed out of date or it couldn’t be found immediately. There seemed to be a lack of understanding what some documents might be for such as the Care Passport. There was also a lack of understanding about end of life plans/DNACPR. Support staff seemed to lack initiative/training and would refer to senior staff/manager for even basic things", “The manager appeared helpful, motivated, and keen but I had a sense she was overworked and unsupported. The office space was chaotic. Care plans were out of date and there appeared to be a ‘laisse faire’ attitude to this. The manager did not appear to know what external support services were available or where to go for help” and, “I had no concerns regarding safety of the residents until recently.”

We were given the daily handover records from February 2024 to 10 March and found important information had not always been recorded to share with staff. We reviewed the encrypted electronic messages and found important information had not always been shared. This meant staff had not always been given the information they needed to meet people’s care needs and we found people had been placed at risk of harm. We shared these concerns with the registered provider who told us, important information was also shared with staff verbally or through nourish, however did not provide us with any evidence to support this.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

People and relatives told us they were not involved in regular reviews about people’s care and not all relatives we spoke with were aware of a care plan. Relatives told us, “There have been no care plan meetings and so obviously no reviews of it” , “I haven’t seen a care plan, the last one I saw was from the hospital about 4 years ago” and, “there are general chats but no reviews of care, I have never been invited in for a meeting.”

The registered manager told us they were aware care plans had not been reviewed regularly. The registered manager told us this was because they had been covering staff who were either on annual leave or on sick leave and had not had time to fulfil their own job role. The registered manager told us they intended to start reviewing care plans following our inspection. The registered manager did not tell us how people or relatives were involved in reviews about their care. The provider told us, “The registered manager has always been proactive in communicating with relatives on any care changes. This is either over the telephone or informally when relatives visit. In addition, the frailty nurse reviews with the registered manager and relatives an annual Dorset NHS care plan which is then shared with relatives.” However, we were not provided with any evidence to support this feedback. The provider told us all care plans were reviewed and updated following our inspection, however, did not provide us with any to review to ensure they reflected the needs of people and how to achieve the best outcomes for people in accordance with best practice guidance.

There was not a robust process in place to ensure care plans were regularly reviewed and this had led to care plans not reflecting what people needed to ensure their care needs were met. Care plans did not always include people’s care needs or when they did, did not always include instructions staff should follow to prevent the person from becoming unwell. Care plans did not always include people’s likes, dislikes and preferences and did not demonstrate people or their relatives had been included in the creation of care plans. Care plan audits had not identified the shortfalls we found during our inspection. The provider told us they completed a full review of people's care plans following our inspection and ensured care plans reflected people's likes, dislikes and preferences. The registered provider told us family input was also recorded, however, did not provide us with any updated care plans to review to ensure they reflected the needs of people and how to achieve the best outcomes for people in accordance with best practice guidance.

Staff told us they asked people for their consent before they commenced care however, during our inspection we observed 2 members of staff assisting 1 person with moving and handling. Staff did not explain to the person what was happening or seek consent before they started. Relatives told us they were not sure whether staff sought consent from their loved ones. One relative said, “I wouldn’t know about that” and another said, “they tell them what they are going to do.” Some people living at Goldcrest lacked capacity to make decisions. Relatives provided us with mixed feedback when we asked if they were involved in making decisions in their loved ones best interest. Comments we received included, “Now and again they might ask me but not always” , “they are always in touch with the family” and, “not once so ever.”

Staff told us how they sought consent before providing care. One staff member gave an example of seeking consent from a person who was non-verbal. “[Person] does not speak but will shake their head or open their mouth to indicate they consent to eating.” Staff did not always understand the mental capacity act. One staff member did not understand what inspectors meant by mental capacity. We explained several times however, the member of staff was unable to tell us what they would do should they have concerns a person lacks capacity. Another staff member told us they understood the mental capacity act however, had not reviewed the mental capacity assessments or best interest decisions. The registered manager told us “When I set up a care plan on the [electronic care planning] system, as I put in the pre assessment information, it highlights where you need to go so, I would do a mental capacity assessment. I make sure people have assessments completed. I also contact various people like advocacy and social workers.” However, we found mental capacity assessments had not been completed appropriately. The registered manager told us they would complete a mental capacity assessment for people who lacked capacity to consent to equipment that would restrict their independence. “I would do a best interest assessment for the alarm mat as it's restraint, I would do an assessment for personal care and best interest.” However, we found mental capacity assessments had not been completed appropriately. The provider told us, “Best interest assessments were completed for all residents within the timeframe of the inspection.” However, did not provide us with any evidence to demonstrate this.

Where people lacked capacity to make decisions regarding their care and treatment, mental capacity assessments had not been completed in line with the principles of the Mental Capacity Act (MCA). We reviewed the care records of 4 people who lacked capacity to consent to care and treatment. 3 people had 1 generic mental capacity assessment in place for ‘all aspects of care’ This means the mental capacity was not decision specific and was no in line with the principles of the MCA. We observed 2 people who lacked capacity had restrictive alarm mats in situ in their bedrooms. Mental capacity assessments had not been completed to assess the persons capacity to consent and a best interest decision had not been made in accordance with the MCA. This meant people had been placed at risk of unnecessary restraint. Training records showed 2 members of staff had not completed mental capacity act training since they started working at the service 5 weeks previously. We discussed this with the provider who told 1 person had completed training in July 2023, this was however with another service provider. Four staff had not completed mental capacity training or had their competency checked in the past year in line with best practice guidance. This meant people were at risk of staff not knowing the latest guidance and best practice information to ensure people were supported. This meant the service could not be sure all staff understood the requirements of obtaining consent to ensure they were working within the principles of the MCA.