Gloucester House

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We identified a breach of the legal regulations, people were not always receiving effective care. The provider was not following the guidelines of the Mental Capacity Act when recording decisions. When people had capacity to make decisions, their wishes were not always respected by the provider. People’s needs had been assessed and reviewed, however, the review had not always been documented. Relatives told us, they felt nurses and care staff did not always work as a team. People had access to health care professionals and were supported to live as healthy lives as possible.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People and relatives said that they were asked about their or their relatives needs before they moved to the service. “Yes. I was involved in the assessments before they moved in”. They told us that these needs continued to be assessed and updated on a regular basis. A relative told us staff started to support their family member to eat as they were struggling. Staff then provided some adapted cutlery to the person so they could eat by themselves. The relative told us, “This was great as she likes to be independent.” People and relatives said staff took time to ask people about how they spent their time before moving to the home. This included their occupation, family and hobbies. One relative said, “This was a really good idea as it helped staff to get to know my family member better. It really showed that staff were interested in him.”

The deputy manager described the process they followed when accepting a new person to live at the service. They told us a full comprehensive assessment of people’s needs was completed to ensure the staff could support people in the way they preferred. The initial care plans and risk assessments were then reviewed regularly or if someone's needs changed. However, this had not always been completed and care plans had not always been reviewed.

Processes were in place to assess people’s needs initially but care plans had not been updated or changed following reviews.

People and relatives said that staff knew them well including what was important and mattered to them. However, there was some inconsistency in staff putting this knowledge into practice to improve people’s well-being. During an activity, staff were skilful in engaging people in the discussion topic as they knew people’s interests and communication needs. However, although the deputy manager told us lunchtime was a focal point to encourage socialisation and encourage people to eat, we did not always observe this good practice. There was limited conversation between staff and people during lunchtime. Staff appropriately sat beside people they were supporting to eat but there was very limited or no conversation with the people, such as letting them know what they were going to eat.

The deputy manager told us, “Staff have to evidence what interactions they have had with the residents. Both myself and the registered manager monitor this. We get alerts if certain parts or tasks have not been completed, such as nourishment. We will then address this with the staff who are responsible. All interactions are therefore evidenced on (our electronic system) Nourish. We have a private messaging app within Nourish which allows us to handover important updates or information between us all. Nourish has been a good thing, when you have finished assisting or doing personal care, you do it straight away, the paperwork was left a couple of hours. That is when you forget, now it is an automatic thing when you leave the resident."

The electronic system gave staff a task list which had been assessed as being required by the person’s care plan. However, there was not always guidance for staff about how to complete the required support and what to do if someone was unwell. For example, one person was living with epilepsy, there was no guidance about how a seizure may present and what action to take to keep them safe.

People and relatives told us, they were not sure how well the staff team worked together. A relative told us, “They write it in the book that something happened and I am not sure that goes any further, it comes back to the feeling I have that nurses are nurses, carers are carers. Sometimes a comment to the nurse is not being transmitted down to carers.”

Staff described occasions where they had been required to work with only agency staff. At times staff told us, they had been responsible for people's support which they were not confident about and they were worried and had not felt supported.

We requested feedback from professionals who visit the service, we did not receive any specific information about how staff worked together. The service supported the local NHS and local authority arrangement and accepted referrals for people who require discharge from hospital and short-term care to enable a further assessment of their needs.

The management team informed us that the nursing and care staff liaise with many external healthcare professionals to ensure that there is joined up working. These professionals included, for example, the dietician. However, care plans did always contain all the guidance provided by health professionals to support people safely.

People told us that nurses undertook regular checks of their health to ensure their ongoing health and well-being. One person told us, “When I am poorly or down the staff are really good to me.” Relatives said that they were informed of any health care appointments in advance so they could make the appropriate arrangements to escort them to any health checks. Another told us, “Yes the couple of incidents when she’s been particularly unwell, I’m kept in the loop.” and “I’m certainly informed, the nurse phones me,”

Staff told us they did not always have the staff to support people to live as healthy lives as possible. There was not always enough staff to provide the support needed such as changing people's position when they were at risk of skin damage.

Processes in place were not always effective in making sure staff had the guidance to support people to be as healthy as possible. There were no system in place to ensure people were being supported in the way they preferred such as promoting their independence and choices.

People and relatives told us, they were supported and their support was reviewed with staff when their needs changed. People told us, staff changed how they supported them when required.

Staff told us, they were kept informed of changes to people's needs and support, but this was not always written in the care plans.

Audits and reviews of people's care plans and risk assessments had not been effective in identifying when people's needs changed. There was limited guidance about the expected outcomes of the support given including when care staff were supporting people with complex needs. There were limited checks to assess if the support people received was meeting the required outcomes, such as maintaining oxygen levels or meeting a target weight. Nurses provided clinical support to people with complex needs but they did not have the time to check the support given by care staff to make sure people received appropriate care.

Two people, who had been assessed as having capacity were not supported appropriately when they made decisions. Some people's decisions had not been respected and staff had made a different decision. For example, one person who had capacity about where they wished to receive their support decided they would like to go home. However, the registered manager, had inappropriately applied for a Deprivation of Liberty Safeguards authorisation to restrict them to stay in the service. Another person had a detailed mental capacity assessment about where they would like to receive their care. It was clear they wished to return home with a care package, they were asked about what they would do if they became unwell. The person understood they would need to press the lifeline button, it was recorded this response showed the person understood how to keep themselves safe and had capacity to make the decision. However, further records stated a best interest decision was made, regardless of capacity, stating the person had mental capacity to decide to live in their own home again, however their current medical condition would advise against that. And the person remained at Gloucester House. People told us staff asked about their choices in their day to day lives such as what they wanted to wear and what they wanted to eat at mealtimes. At lunchtime staff checked with people before assisting them to eat and people had finished their meals before clearing their plates. Some people were not able to move around their home without assistance. Staff explained to people how they were going to assist them and gained their consent about which room they wanted to be helped to.

Staff told us, “We have someone who cannot speak, they put their thumb up or down, we have come to that arrangement. If somebody cannot react at all, it would be a best interest decision, I ask a senior, I get nervous if I am not doing the right thing or check with another member of staff to come in with me.” We use implied consent for example, we want to take bloods, if they reach out a hand we take it as that or offering fluids if they open their mouth. We always try and get consent, in the care plans for a few people if they decline care if there is no capacity we can come an hour later and they will be compliant later. We follow their desires; we would never force someone to have care. There were no detailed records to show how staff had gained consent from people to support their actions.

Processes were not effective in making sure people who had capacity had signed consent forms that were pertinent to receiving care. However, they had signed the social media and photography consent forms. The principles of the Mental Capacity Act (MCA) had not been followed in some cases. Not everyone who had been recorded as having ‘no capacity’ had the required mental capacity assessment to evidence how the determination was made and in relation to a specific decision. People who had been assessed as lacking capacity had ‘make sure consent is gained’ throughout their care plan, but not how this should be completed. Documents recording people's capacity lacked detail. For example, one person's record simply stated cannot understand, cannot retain, cannot weigh up and cannot communicate. This was not respectful or supportive of the person's rights. The MCA requires staff to assume people have capacity until it has been assessed they have not, and this should be recorded. The process had not been followed, records stated people did not have capacity but there was no evidence about how the determination was made.