Goldenley Care Home

Social Care Org · South West

Overall Rating
Inadequate Last inspected 3 July 2017
Domain Ratings
Safe
Inadequate
Effective
Requires Improvement
Caring
Requires Improvement
Responsive
Requires Improvement
Well-led
Inadequate

View Full CQC Report

7 must-do actions

Must-Do Actions (7)

Legal requirements based on regulation breaches identified during inspection.

Must Do
Safe
The provider must ensure that all staff receive appropriate and up-to-date training in safeguarding people from abuse.
Regulation 13 (Safeguarding service users from abuse and improper treatment)
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.
Must Do
Safe
The provider must ensure that care and treatment is provided in a safe way for service users, including identifying and addressing potential risks, analysing accidents and incidents, maintaining equipment, ensuring a safe and hygienic environment, and managing medicines safely.
Regulation 12 (Safe care and treatment)
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 …
Must Do
Effective
The provider must ensure that care and treatment is provided only with the consent of the relevant person, in line with the Mental Capacity Act 2005, including appropriate best interest decisions and staff training.
Regulation 11 (Need for consent)
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 …
Must Do
Effective
The provider must ensure that persons employed receive appropriate support, training, professional development, supervision, and appraisal necessary to perform their duties.
Regulation 18 (Staffing)
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 …
Must Do
Caring
The provider must ensure that service users are treated with dignity and respect at all times.
Regulation 10 (Dignity and respect)
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.
Must Do
Responsive
The provider must ensure that care and treatment is appropriate and meets the individual needs of service users, including person-centred care planning and responsive support.
Regulation 12 (Safe care and treatment)
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 …
Must Do
Well-led
The provider must ensure that effective governance systems are established and operated to assess, monitor, and improve the quality and safety of the services provided, and to maintain the premises and environment.
Regulation 17 (Good governance)
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 …

Previous Inspection (20 April 2017)

Rating: Requires Improvement Type: Focused inspection Actions: 2 should-do
2 repeated
Location Details
CQC ID: 1-110960503
Local Authority: Wiltshire
Region: South West
Inspection Report
Type: Comprehensive inspection
Date: 3 July 2017
Rating: Inadequate
Actions: 7 must-do
AI-extracted 17 Feb 2026