Greenmore Healthcare Services Ltd

At the time of our inspection, the service was supporting people with specific needs linked to a learning disability or autism, but they were not in receipt of a regulated activity. However, we assessed the care provision under Right Support, Right Care, Right Culture, as the service is registered as a specialist service for this population group. We found some improvements were needed for the provider to meet the principles of ‘Right support, right care, right culture’ and these are reported on within our full report.

This is the first assessment for this newly registered service. We found 3 breaches of regulation related to safe care and treatment, safe recruitment of staff and governance of the service.

Systems and processes had not been developed to monitor and improve the safety and quality of the service. The provider was not yet familiar with the regulations. We found numerous omissions in documents we expected to be in place to ensure the safety of the service. This included medication administration records, body maps and medicine protocols to support staff in the safe handling of medicines. Some risk management plans were not in place and staff did not always have the information to refer to when needed.

We identified 3 safeguarding incidents that had not been reported to us as legally required because the provider had not been aware of the requirement to do this. However, some actions had been taken by the provider to act on the information of concern.

Safe staff recruitment did not always take place because pre-employment checks were not always completed. We could not be assured staff had always completed all of the training they needed, and the provider had not assured themselves of staff’s skills, as no competency checks had been undertaken.

Despite the concerns we identified, we received positive feedback from people, relatives and staff. There was strong evidence of a supportive provider who valued their staff team, worked alongside them and had a caring hands-on approach toward people and their relatives.

The provider welcomed our feedback and took some immediate actions to make improvement. This included putting medication administration records into place.

We have asked the provider for an action plan in response to the concerns we found at this assessment.