The Care Quality Commission (CQC) has rated Gresley House Residential Home in Swadincote, Derbyshire, inadequate and placed it in special measures following an inspection in November.
Gresley House is a residential care home providing personal care for up to 37 people. The service provides support to adults, including some who have dementia. At the time of this inspection there were 30 people using the service.
This unannounced focused inspection was prompted in part due to concerns received about risk management in the home.
Following this inspection, breaches were identified in relation to managerial oversight, personalised care, safeguarding and risk management.
The home’s overall rating has now dropped from requires improvement to inadequate. It has also dropped from requires improvement to inadequate for being safe and well-led. Being responsive has declined from good to requires improvement. Effective and caring remain rated as good.
The service is now in special measures which means it will be kept under review, by CQC and re-inspected to check sufficient improvements have been made.
Greg Rielly, CQC's deputy director, Midlands network, said:
“When we inspected Gresley House Residential Home, we found the provider had a lack of oversight of the service, which meant issues and concerns weren’t always being addressed which could put people at risk of harm.
“Where risks had been identified, the provider didn’t ensure staff had adequate information or measures in place to prevent and protect people from these risks. For example, someone was at risk of leaving the home unaccompanied, however this information hadn’t been clearly recorded, and guidance for staff was limited, which placed the person at continued risk of leaving the home unaccompanied.
“Additionally, people weren’t always protected from the risk of neglect and abuse. The home had no effective system in place to ensure lessons were learnt when incidents occurred which could result in these happening again.
“It was concerning people didn’t always receive care in a personalised way that met their individual needs and choices. One person's care plan documented they required an interpreter and staff were to use picture cards to communicate; it also stated they had poor eyesight. However, there was no evidence they had been supported with this to enable them to communicate their needs.
“We will continue to monitor the service closely to ensure people are receiving the safe care they deserve. If we are not assured this is happening, we will not hesitate to take action.”
Inspectors found:
- People were not protected from risks associated with their individual needs and wider environment. The provider did not effectively implement measures to reduce risks
- People's medicines were not always managed in a safe way
- People did not always receive care in a personalised way. They were not supported to continue taking part in hobbies that interested them and activities were not developed to support people with specific needs
- Care plans contained incomplete and inconsistent information. People were not supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests; the care plans and systems in the service did not support this practice
- The service relied heavily on agency staff, some of whom we could not be certain had been checked for suitability prior to supporting people
- Staff said they were very rushed and felt they could not spend quality time with people
- There was a lack of identified outcomes and learning from previous incidents and complaints meaning the provider missed opportunities to improve the experience and the safety of people living in the home.