Archived: Goldcrest

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• 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

We identified 4 breaches of regulations. People were not always safeguarded from abuse. There was a lack of systems and processes to ensure restraint was only used when absolutely necessary. Staff had not all received up to date safeguarding training and the service had failed to report 7 notifiable incidents to the local authority. Medicines were not always managed safely, and people had not always received their medicines as prescribed and this had caused people harm and placed other people at risk of harm. The provider failed to assess, monitor and mitigate risks to the health and safety of people living at the home and staff have not been provided with instructions to keep people safe. Staff had not always completed a full induction and staff had not always been provided with up-to-date training in line with good practice guidance to ensure they understood and could meet the needs of people living at the home. We were not assured staff had always been recruited safely into the service. Staff had not been assessed as competent before supporting people living in the home. There was a lack of robust systems in place to ensure the environment was safe and we were not assured the service could prevent the spread of infection. There was little evidence to support a learning culture. Assessments were completed before people moved into the service however, information required to support people was not always provided to visiting healthcare professionals and not provided to new providers of care when people who moved to different services.

This service scored 28 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We received mixed feedback from relatives. Some relatives told us that communication could be improved and felt they were not always informed when an incident happened. Feedback from relatives included, “They let me know if her health has deteriorated”, “The communication could be better; it is hit or miss”, “It would be nice to have more information” and, “It’s pretty good, if she falls, they phone immediately.”

Staff told us they completed paperwork when an incident or accident occurred. Staff were not able to tell us whether they completed reflective practices when things went wrong. One staff member told us they no longer administered medicines “because there have been errors, and they are a mess.”

The registered manager audited accidents and incidents however, the audits did not include details such as the time and the location of the incident. The audit was not effective at identifying any themes and trends, this meant lessons could be learned and actions taken to reduce the incident from happening again. We requested to review the lessons learned when things go wrong process. We were provided with a policy and told staff did learn lessons however, the management team were unable to provide any documentation to demonstrate the effectiveness of this process at the time of our inspection. Following our inspection the provider sent us an example of a lessons learned process from an incident in February 2024. We were unable to assess the effectiveness and sustainability of the lessons learned process as regular use of the lessons learned form had not been embedded. For example, the registered manager had been informed of a medicines error in January 2024 by a healthcare professional. No lessons learned paperwork had been completed to demonstrate learning and actions taken to minimise a future occurrence. This meant the provider could not be assured lessons were learned to mitigate a risk of a reoccurrence and this had placed people at risk of harm.”

CQC received information of concern relating to the appropriate assessments of people before they moved into Goldcrest, and this had informed part of our decision to complete a responsive assessment with onsite inspection of the service. One person had been admitted into the home however, an assessment had not identified all the person’s care needs and this meant staff had not been provided with all the information they required to support them. This led to the person displaying agitation and distress and people living at Goldcrest were placed at risk of harm. We received concerns from healthcare professionals that assessments before people moved into the home were not always effective. One healthcare professionals said, “I believe they do make assessments, but I am not sure the assessment is robust enough given a recent admission where it rapidly became clear that they could not meet the person’s needs.” Relatives were not always certain an assessment had taken place before their loved one moved into Goldcrest. Comments included, “I believe that happened”, “I think I got a copy” and, “the last assessment was 18 months ago.” Relatives were not clear whether this was an assessment Goldcrest staff had completed or a social services review. One person had moved from Goldcrest into a new care home however, staff from Goldcrest had failed to provide an up-to-date care plan, a current list of medicine the person was prescribed and their medicine administration record to ensure safety and continuity of care. This had placed the person at risk of harm.

Staff did not always feel they received enough information about someone when they moved into the service. One staff member felt information was withheld from them and this had led to staff not knowing how to meet the needs of one person who no longer lived at the service as staff were unable to meet their care needs. We shared these comments with the registered provider following our inspection who told us, “All staff had access to the same information, including care plans and assessments.”

Healthcare professionals and care providers told us important information had not always been provided by Goldcrest about the person they were supporting. This meant information to ensure people’s care and treatment needs were identified and met had not been available and placed the person at risk of harm. One healthcare professional said, “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.” We received feedback from other care homes that important information had not been provided when a person transferred between services. This meant the service was unaware of care needs the person may have and put them at risk of harm.

Assessments had been completed before people moved into the home. However, we found staff training was not always up to date to ensure the care needs identified could be met. For example, 8 staff had not completed up to date positive behaviour support training, this meant staff had not been provided with up-to-date best practice guidance to support people when they were distressed, and this had placed people at risk of not having their care needs met. The electronic care planning system had a function staff could use to easily share information with healthcare professionals however, staff had not always used this function to effectively share information and this had led to healthcare professionals not always having all the information they needed to make their clinical judgements.

People who were prescribed sedative medicines to be administered only when required had been placed at risk of being unnecessarily restrained as there were no control measures in place to ensure the medicine was only administered when needed. Between 19 February to 5 March 2024, we found 1 person had been given an ‘as required’ sedative 33 times and 1 person had been given an ‘as required’ sedative 11 times. The reason for the administration of this medicine had not been recorded in the persons medicine administration record or in their care records. This meant we could not be assured the medicine had been administered in accordance with the prescriber's instructions and the person had been placed at risk of being restrained unnecessarily. Relatives told us they felt there had been some improvements with the new management, however one relative said, “In my opinion [loved one] is not being cared for properly.” This supported our findings.

Staff had not identified and reported 7 safeguarding incidents to the local authority safeguarding team and to CQC. This meant external scrutiny was not always possible and people had been placed at risk of harm. However, the staff we spoke with knew how to recognise signs and symptoms of abuse and told us who they would raise concerns with inside the home. Staff told us if they were not listened to, they knew how to raise concerns to externally.

Staff did place people at risk by not following best practice guidance when assisting people with their moving and handling needs. Staff did not always respond to people calling out in distress however, we observed staff talk to people with kindness.

Staff had not always received up to date training. It is best practice for staff to receive annual safeguarding training to ensure they are up to date with current guidance and best practice. We found 7 staff safeguarding training was out of date and 1 staff had not completed safeguarding training as part of their induction. This meant staff had not been provided with up-to-date best practice guidance to keep people safe and this had put people at risk of harm. The registered manager reviewed incidents and accidents however, had failed to identify 7 incidents that were required to be reported to the local authority safeguarding team. This meant external scrutiny of the home had not always been possible to ensure people were safe. People had been placed at risk of harm.

People had been placed at risk of avoidable harm. Assessments had not always been completed to assess people for risks to their health, safety and wellbeing. Where they had, the assessments had not always been effective at identifying the actions staff needed to follow to reduce the likelihood of harm. We reviewed care plans and identified 1 person had not received medicines as prescribed to reduce a risk of harm to their health. We notified the local safeguarding team and a district nurse was arranged. The district nurse was required to perform a medical procedure as a result of this omission and lack of oversight. A person had been harmed. We observed people living with a cognitive impairment were able to walk around the home freely as they wished. However, people had access to stairs and staff were not always around as they were assisting other people. We received feedback from a relative who told us, “[Person] is allowed to walk up and down the stairs when they shouldn’t be. " We reviewed people’s care plan and risk assessments. An assessment had not been completed to identify any risks to people having access to the stairs and this meant actions had not been put in place to reduce the likelihood of harm.

Staff told us they did not always receive enough information to support people, and this had led to people being placed at risk as staff did not know how to meet their care needs. One staff member said, “I do think people are at risk. The management do not always pass on important information we need to know to provide care to people." We found information relating to identified risks had not always been shared with staff including how often people should be assisted to reposition to prevent skin breakdown. We discussed these concerns with the provider after our inspection who told us, “Information was always shared through handover, Nourish or [an encrypted messaging system] and with the Deputy Manager working with staff one to one with any new resident.” However, we were not provided with the evidence to support these comments, and this meant we could not assess the effective sharing of information to ensure people were safe.

We observed staff assisting a person with a hoist. One member of staff applied the break whilst the other staff member hoisted the person up. This meant the hoist was not able to counterbalance as the person was hoisted and placed them at risk of being harmed. We observed cleaning products left in the corridors and in people’s room meaning they were accessible by people who lacked capacity and had placed people at risk of harm.

Risks to people’s health, safety and welfare had not always been assessed. The home had two staircases which were accessible by all the people who lived in the home. Two people walked around independently who were deemed to lack insight into their needs and understand what might harm them. An assessment to identify any risks from the staircases had not been completed. This meant staff had not been made aware of any actions they should take to reduce the likelihood of an incident. This had placed people at risk of harm. Assessments had not always been completed to assess people for any risks of skin deterioration, from falls and from not understanding and being able to use the call bell. This meant actions had not been identified for staff to put in place to reduce the likelihood of harm. A care plan audit completed in February 2024 had failed to identify the shortfalls we identified during our inspection.

Relatives did not have concerns about the environment at the time of our inspection. Relative's comments included, “Everything seems ok” and, “I haven’t seen any problems.”

Staff said they reported concerns to the registered manager during handovers. One staff member told us, “[person] had to wait 2 weeks for their toilet to be fixed. [Person] spends a lot of time in their room and had to use a commode until it was fixed. I was upset for them they had to wait so long.” We shared these comments with the provider who told us, “The issue with the toilet was investigated immediately by maintenance but identifying and fixing the problem did take longer due to a complication.

Some areas of the environment had been recently decorated since our last inspection and were light and bright. This included communal areas including the lounge and some bedrooms. No people were living in those rooms at the time of our inspection. During our onsite inspection we identified areas of the environment which posed risks of harm to people living at the home. The carpet was torn and lifted in the downstairs hallway and in 1 persons bedroom putting people at risk of tripping. Rooms on the first floor containing hazardous items including irons were unlocked and accessible to people who lacked capacity. Blocks to cover exposed radiator pipes on the first floor were not secured meaning people could trip and fall. One person’s ensuite had razors and scissors left exposed on the sink and accessible to people who had been assessed as lacking capacity. Cleaning products were left unattended in people’s room and in the ground floor hallway and were accessible to people walking past who had been assessed as lacking capacity. People had been placed at risk of harm.

A maintenance request form had last been used in December 2023. We asked the provider whether there were any outstanding works going on and the provider told us they were up to date with everything. This meant they had not identified the same concerns we identified on the first day of our inspection. We fed back our findings and on the second day of our inspection the carpet had been made safe and the bed rail bumper had been replaced. An environmental audit had been completed in November 2023; this is not in line with the providers policy which states environment audits will be completed on a 1–3 month basis. The environmental audit had failed to identify the shortfalls we found during our inspection.

Relatives told us there were enough staff to meet the need of their loved ones. Comments included, “they could always do with more at weekends but then I am not sure”, “I think there are enough staff” and, “yes there is enough staff whenever I visit.” We asked whether relatives felt staff were well trained. Relatives were positive about staff however felt they did not always have the training they need. One relative said, “I don’t think there is any training going on.”

Staff we spoke to had not all completed up to date training. Staff felt the training they had completed was not always to a good standard. One staff member told us, “We are asked to watch training DVD’s during our work time. I find it difficult to do as we have all our other duties that we need to do so we do not get the time.” We fed this back to the provider who told us, “Time was always allocated for training.” We spoke with 2 staff who told us they had completed shadow shifts but had not completed training since they started working at Goldcrest. Staff told us they had not received face to face moving and handling training. We fed this back to the provider who told us, “The registered manager and deputy manager both completed train the trainer training and staff were observed to be competent.” The registered manager told us they did observe staff but could not find records to demonstrate staff were competent to fulfil their roles. Staff told us they did not always receive regular supervisions and appraisals. One staff told us, “I get very irregular supervisions, I think I last had one about a year ago.” And another staff member told us, “I have never had a supervision or appraisal.” We fed this back to the provider who told us, “The registered manager held regular supervisions/one to ones with copies in staff files. Staff had signed supervision agreements, and a supervision matrix was posted in the office.” However, we reviewed 5 staff files during our inspection and found supervisions had either not been completed or had not been completed since 2021.

We observed staff using the hoist incorrectly and found they had not completed training whilst working at the home or received competency checks to ensure they understood and knew how to support people safely. However, we observed staff speaking with people in a kind way.

The registered manager told us staff were required to watch DVD’s and certificates were issued by the provider once staff had completed a quiz to demonstrate their knowledge. The provider told us, "staff were sometimes required to receive DVD training which involved training handouts, group discussion and completing questionnaires. Training was also provided using online services." We were provided with a training matrix to show staff had completed training however, we identified staff training was not always up to date. For example, 6 out of 10 staff had not completed up to date moving and handling training, 3 staff fire training was out of date and 3 staff oral health training was out of date. We had received concerns that staff were not always able to support people who displayed behaviours due to their health conditions. The training matrix showed that 2 staff had not completed positive behaviour training and 7 staff had not completed up to date positive behaviour training. This meant staff were not always provided with the up-to-date skills and knowledge to carry out their duties, this placed people at risk of harm. The providers governance policy stated audits relating to staff supervision and training would be completed 1-3 monthly. We checked we had been provided with all the completed audits and the registered manager confirmed we had. We were unable to find any audits relating to supervision and training. The provider had a condition of their registration at Goldcrest to audit staff recruitment files. At our inspection we were unable to find records to demonstrate staff recruitment audits had been completed. We brought this to the attention of the provider who sent us a completed audit after our inspection. Their audit failed to identify the shortfalls we found during the inspection and did not contain any actions taken to meet compliance. This meant we could not be assured the audit had been effective.

Relatives told us the home had been cleaner since our last inspection. We received comments including, “It smells better, yes, it is better than it was with the new management”, “It’s a lot better cleaner” and, “It is adequately clean yes and PPE seems fine.”

Staff told us they had plentiful access to PPE.

We identified areas that could not be cleaned, and this put people at risk of the spread of inspection. For example, signs had been put up around the home that had not been laminated, this meant they could not be cleaned and could contribute to the spread of infection. The first-floor bathroom was unlocked and accessible. The sink had a buildup of limescale, the bath had cracks and paint was peeling from the wall and the ceiling meaning these could not be cleaned to prevent the spread of infection. The provider told us people did not ask for baths and were assisted to have showers instead meaning the bathroom was not in use at the time of our inspection. Following our inspection the provider told us the bathroom was now securely locked. One person’s bed rail bumper was scratched and peeling meaning these could not be cleaned. The laundry room had limescale build up in the sink, no hand towels to dry hands, dirty floors and a household waste bin overflowing with red sacks meant for yellow hazardous waste. The bin lid had to be touched to open and was not operated by using your foot which increased the risk of the spread of infection. However, the home appeared to be clean on both days of our inspection.

People had not been assessed for their susceptibility and risks of the spread of infection. We reviewed 6 care plans and could not find documents to demonstrate Individual assessments had been completed to assess the person's risk from infection. We requested to review the overall environmental / infection prevention and control risk assessment of the home during our onsite inspection. The registered manager was unable to find the environmental assessment. The provider sent us a copy of the health and safety assessment a few days later however, this had failed to assess people and the environment for risks from the spread of infection. An infection prevention and control audit had been completed in September 2023. The governance policy stated audits would be completed 1-3 monthly; this meant the audits were out of date. The audit had failed to identify the concerns we found during our inspection. People had been placed at risk of harm.

Systems and processes were not robust to ensure medicines were administered as prescribed. We identified incidences where people had not received their “as required” medicines when they needed them, and this had caused them harm. We identified 1 person had been prescribed as required pain relief medicine as they were calling out in distress and had told staff they were in pain. The “as required” medicine was received and booked into the home on a Friday. Staff recorded in daily notes that the person had been shouting out in distress on the Sunday evening, however pain relief medicines were not administered until the Monday Morning. We were unable to find evidence to demonstrate staff had been informed the person had been prescribed “as required” medicine due to being in pain and no as required protocol was in place at the time the medicine was received. We reviewed this person’s medicine administration records (MAR) and found from 26 February to 29 February 2024, staff had recorded “none available” for the persons regularly prescribed analgesia. No further stock had been signed in on the MAR however, from 1 March 2024 to 6 March 2024 staff recorded ‘R’ for refused or ‘O’ for other. On the night staff recorded the person as shouting in distress they had recorded ‘O’ for the persons analgesia but had not record the reason why the medicine was not administered. The provider had not ensured systems and processes were robust to ensure the safe administration of medicines as prescribed and this had caused 1 person to be in unnecessary pain. Relatives told us they had no concerns about the administration of medicines.

The registered manager told us only 5 members of staff were able to administer medicines. One staff member said, “the last manager arranged medicine training, that was the last time I completed medicine training and would have been around 2022.”

We observed medicines being administered from the medicines room, a locked cupboard only accessible by staff who were trained to administer medicines. In the medicines room we found controlled high-risk medicines that were no longer prescribed but were being stored longer than was necessary. This meant they were accessible and were at risk of being used inappropriately placing people at risk of harm. We found a controlled high-risk medicine had been administered the morning of our first site visit however, had this not been countersigned by staff. This meant the provider could not be assured the right medicine had been administered to the right person. Medicine tablets had been left in pots with no name. When we asked the registered manager about this, the registered manager did not know who they belonged to. Eye drops meant to be stored in the refrigerator, were being stored in the medicines trolley and had been opened more than the instructed 28 days. This meant people were at risk of being given out of date medicines that did not work as they had been stored at incorrect temperatures. Reasons for omissions of medicines had not always been recorded. The reason why as required medicines had been administered had not always been recorded. As required protocols to give staff instructions of when, how and why to administer medicines were not always in place. Staff had not been provided with body maps and instructions of where, when and how to administer topical creams. This had placed people at risk of harm. The provider told us body maps and instructions had been placed in people’s rooms after our inspection, however, did not provide us with evidence for us to review that these were appropriate and effective. Best practice and NICE guidance recommend care home staff medicines knowledge and competence is assessed at least annually. The training matrix sent to us by the provider showed 4 staff out of 5 medicine training was out of date.