Goldenley Care Home

⚠ Training records showed that some staff had not completed safeguarding training or had not received updated training, and one staff member completed training a month after starting employment.

⚠ Potential risks to people's safety were not sufficiently identified or addressed in assessments. Accidents and incidents were not analysed to minimise further occurrences. A pressure-relieving mattress was faulty and not identified by staff. Action taken to ensure a person's safety after leaving the home unsupported was insufficient. The laundry door …

⚠ The principles of the Mental Capacity Act 2005 were not always followed, with restrictions like cigarette management not formally agreed. Best interest meetings were not held for decision-making, and a relative was asked about resuscitation for a person believed to have capacity. The administrator was inappropriately identified as the 'consent …

⚠ Not all staff received recognised induction programmes like the Care Certificate. Apprentices lacked a clear training and development plan. Many staff had not completed mandatory training courses (e.g., moving people safely, first aid, infection control, challenging behaviour), and training deemed 'not applicable' was required for some roles. Supervision meetings did …

⚠ Staff interactions were often task-related, lacked pleasantries, and sometimes involved talking over people or discussing personal details in front of them. Brusque responses were given when people approached the kitchen door. Some beds were untidy and uncomfortable, not promoting dignity. Daily records contained undignified, judgemental, or inappropriate terminology.

⚠ Support plans lacked clarity and detail, were not person-centred, and did not provide sufficient guidance for staff on managing risks (e.g., pressure ulceration, leaving the home) or supporting personal care resistance. Staff were not always responsive to people's needs, such as assisting with meals or addressing distress. Activities and stimulation …

⚠ Arrangements to monitor quality and safety were not effective, and improvement had not been sustained. Audits were not comprehensive or effective in identifying shortfalls. The environment was not well-maintained, with rubbish, collapsed walls, offensive graffiti, dirty guttering, and unhygienic items in the garden. Some internal areas, like bedroom walls, had …