Preston care home requires improvement after "serious incident" sees person harmed

The Care Quality Commission (CQC) visited Greenways Rest Home in Clayton Brook, near Bamber Bridge, after they received concerns relating to staffing levels and training, medicines and fire safety. The overall rating had changed from good, which it received in 2019, to requires improvement based on concerns found.

A report published in June 2022 stated that "people were not always protected as not all aspects of risk were being managed safely". It also noted in February of last year the fire service had "identified several areas of improvement and issued an enforcement notice". Furthermore, the home did not record all incidents which occurred on the premises had been "recorded, monitored and audited to reflect any themes or lessons learned". It was then recommended that the provider consider how to become compliant with fire safety guidance, how to make sure lessons were learned, and to make sure knowledge regarding regulatory requirements was up to date.

At a most recent, unannounced inspection of the home carried out on October 19 and November 8, 2022, prompted in part by a notification of an incident in which a person using the service was harmed, it was found that improvements had been made regarding learning lessons and understanding of regulatory requirements, however actions regarding fire safety were still required. The published findings released on December 21 showed safety was still rated as ‘requires improvement’ as, even after a ‘serious incident’, they found that exits from the property were not “sufficiently secured” before or after the incident. This meant that “any risk of avoidable harm was not minimised.”

In terms of the ‘serious incident’, the inspectors found that the registered manager and nominated individual had not followed the duty of candour guidance. The intention of the duty of candour legislation is to ensure that providers are open and transparent with people who use services. This means that staff must inform people about the incident, providing reasonable support, honest information, and an apology when things go wrong. However, the inspectors added: “This was a sensitive situation and was addressed following feedback.” Further work was also needed to become compliant with fire safety guidance and people were not always protected from the risk of unsafe medicines management.

The inspectors also found that one person needed covert medicines, meaning the medication had to be hidden in their food or drink without them knowing. However, this had not been improved from the last inspection and the person was refusing their medicines regularly. Two people also needed thickeners added to their drinks, to reduce the risk of choking, but staff failed to record how much was being added to drinks so the inspectors could not be sure people were receiving it as prescribed.

It was noted however that the registered manager was committed to further learning to make improvements, and "a positive culture" was found at the service. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

At the time of the inspection, the home which provides personal care for up to 30 elderly people and those living with dementia, there were 18 people using the service. A follow up is now in the pipeline with an action plan requested from the provider to understand what they will do to improve the standards of quality and safety.

The CQC concluded its report by saying: "We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect."