Gloucester House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We found the service had deteriorated since our last inspection. We identified a breach of the legal regulations. People were not always in receipt of safe care and treatment. Potential risks to people’s health and welfare had not always been assessed and there was not always detailed guidance for staff to follow. Accidents and incidents had not always been analysed to identify patterns and trends and act to reduce the risk of them happening again. Medicines were not managed safely. Staff were not always deployed effectively to meet people’s needs. However, people were protected from the risk of infection. The building and environment had been well maintained.

This service scored 53 (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 they were confident to raise any problems or concerns with a member of staff or management team. They told us, when they had done so they had been listened to and action taken to resolve their issue. One person told us, “Staff go the extra mile. If you say you need something, then it arrives.” Another person told us, “I raised a complaint about a staff member. I told the nurse and now I do not see that member of staff anymore.”

The deputy manager told us that accidents and incidents were raised by staff through the electronic care planning system. Staff confirmed they reported incidents and accidents in this way. Reports were reviewed by the management team, the deputy manager told us, lessons learnt were recorded on the electronic system. Any changes were then cascaded to the staff including physiotherapists. We reviewed risk assessments of people who had fallen more than once and did not find any evidence risk assessments had been updated following an incident or accident, or lessons learnt. There were no details about the falls and the action needed to reduce the risk of these happening again

The deputy manager completed daily walk arounds to monitor, review people and staff interactions to ensure that any poor practice or concerns could be identified and actioned as soon as possible. The processes in place had not been effective in recording all the incidents and accidents. People and relatives told us about incidents which had occurred and there was no record of these on the electronic system. People had been placed at risk, as action had not been consistently taken and there was no evidence lessons had been learnt.

One person said they told the registered manager during their assessment they were unhappy with their previous care home. “The manager got me here (to Gloucester House) really quickly after they knew that.”

The management team described how they assessed people before they moved into the service. People met the management team and a pre-admission assessment was completed which covered all areas of their care.

There had been no feedback from partners about how the staff supported people to transition between services.

A pre assessment had been completed for each person who had moved into the service. A care plan had been developed once the person had been settled into the service.

People told us they felt safe living at Gloucester House. Some people wore a call bell around their neck which they could use to call for help. One person told us, “It is comforting to know I’ve got a buzzer on.’ Relatives told us they were kept well informed about any aspects of their family members safety, such as if they had a fall. They said regular communication about their relative’s health and well-being reassured them about their safety whilst living at the service. “We’ve never had a problem with anything really, she’s well looked after, cared for and it’s clean, everyone is friendly, she feels very happy and secure there which is the main thing, if she wasn’t we’d look further, we can see she is quite content there and she’s got used to it now, she’s doing fine.”

The deputy manager told us, staff received regular safeguarding training. Staff meetings were held where concerns could be raised and discussed and there was a safeguarding audit completed each month. The deputy manager told us, there were no open safeguarding concerns. When there are, the management team investigate and it can only be ‘signed off’ once the management team input has been recorded. Some staff told us, they were reluctant to raise concerns with the management team, as although they were listened to when they had raised issues no action was taken. Staff described what actions they would report and how they would escalate the concern if no action was taken.

People were relaxed and at ease in the company of staff. After an activity, staff chatted with people about the things they had enjoyed about it, sharing a smile and laughter. When another person said hello to a staff member they touched heads as a sign of understanding and affection between the two of them. When one person was not able to hear what a staff member was saying, the staff member moved position to face the person so they could hear and lip read what they were saying. Then the person nodded to acknowledge they had understood. We observed staff were not deployed around the service appropriately. Although no one was calling out or distressed there was a concern that if there was an emergency, there would not be enough staff available to keep people safe.

The processes in place had not been followed and were not effective in raising concerns. There were incidents which had not been identified as potential safeguarding concerns and had not been raised with the local authority, placing people at risk. For example, members of night staff were sleeping on shift. A member of staff reported this to the registered manager who responded and completed a spot check at night. They found staff sleeping on shift, action had been taken but the incident had not been raised as a safeguarding concern.

People told us there were lots of activities both in the home and trips out. People who had limited mobility said they were able to take part and kept safe during these excursions. One person told us specifically about a river trip they had enjoyed where they could steer the boat. Another person told us, ‘It is amazing here. It has got all you need. I feel very relaxed.’ However, a person’s relative told us about staff not understanding how to support the person to use equipment essential to keep them well. They described an incident when the nurse called them and stated the person was poorly. However, staff were not using the equipment correctly. We reviewed the care plan and there was no guidance for staff about how to use the equipment. There was no information about what action to take in an emergency.

Staff told us, “I would say it is (risk assessment) a broad general overview and sometimes they are not updated enough. We all do shift work, for example I can go in on Monday someone is drinking and by Friday they are having thickener in, sometimes it is not updated from Monday – Friday and people tell you the updates. Sometimes the communication side of things is a bit slow.” We found risk assessments had not been updated when people's needs changed.

During the assessment, we walked around the whole building and only met one member of staff. We had concerns staff were spread about the building, and would not be able to attend an emergency quickly. People had complex clinical needs which nurses were required to support them with. The nurses on duty during our assessment, were required to spend long periods of time with people, leaving others at risk as there were no other nurses available if there was an emergency.

Processes in place were not effective in identifying and providing guidance to manage risks and keep people safe. There was no guidance in place for staff to recognise signs and symptoms of health conditions. There was limited guidance for care staff in the care plans to provide support to people with complex health needs and conditions. There was an over reliance on nurses to support care staff, however, nurses time was limited, and they were not always available to support staff. Risk assessments were not personalised and did not link to each other to give an overall view of people’s risks. When people had equipment in place to support their airway, the risk assessments were the same, even though people’s needs were different. There was limited guidance about how the person displays they are unwell and when to call the emergency services. Some people received their nutrition through a tube and were nil by mouth. There was no guidance for staff about the risk of choking while giving essential mouth care. Risk assessments were generic and seen recorded in other people’s care records, though people did not have the same care needs or risks. Documents used standard phrases produced by the electronic system and not specific to people’s actual needs and risks. For example, diabetes care plans stated what to do if the person had low blood sugar and was alert. However, there was no guidance for when people were not alert and may need immediate medical intervention. People were not always supported according to their assessed needs. People who required 30 minute checks through the day and night as they could not use a call bell, however, they were being checked every 1 – 1.5 hours. Others who required re-positioning were not being supported at the required intervals. One person who was at risk of pressure sores should have been re-positioned every 4 hours. However, there were gaps of between 4 – 7 hours shown in their daily records.

People were complimentary about the environment. Some people showed us they had brought their own furniture with them when they moved to the service which was important to them. People said they could spend time in their rooms or in the lounges with other people. One person told us how when they had friends to visit they were able to sit together in the library rather than the dining room so the meal was more intimate. Another person told us they liked to walk every day in the garden and also around the corridors which were long and circular which gave them a good amount of exercise. People were very positive about the garden area which had a number of seating areas and also showed us the range of large animal figures such as a tiger and elephant which they said they enjoyed looking at. Comments included, “It certainly is safe; I have never had any worries about the safety. It looks presentable and clean, there is a cleaner in every day.” And “I keep saying to the cleaner that if they want to come to my house they can, they are cleaning all the time. Every time I come in they are around; the environment is good.”

The registered manager told us, there were enough domestic and maintenance staff, to keep the environment safe for people.

We did not have any concerns in relation to the safety of the environment. The service was clean and there were no obvious hazards around the building. People were cared for in a safe and clean environment that was designed to meet their needs. The corridors and communal areas were spacious, people who used a wheelchair had sufficient room to do so safely. There was a range of equipment to help people move around their home such as hand rails and hoists. There were a number of different areas where people could sit and we observed people using these spaces. Staff were observant of people’s safety needs. For example, when a staff member was propelling a person in their wheelchair they advised them to put their arms in when moving through a narrow doorway so they did not hurt themselves.

Regular maintenance checks were completed to ensure that the environment was safe. We reviewed records of servicing key pieces of equipment and these had all been completed appropriately.

People and relatives said there were enough staff to respond to their needs. They said there was a consistent staff team and many of the staff they had known since first moving to the service. Comments from people included, “The staff are perfectly fine. I have the help when I need it” and “I can depend on most of the staff. It is better when I have the permanent ones for this floor. At night, the staff come when you call.” People and relatives were complimentary about the kindness of staff. Many people highlighted the enthusiasm and dedication of the activity lead and all the events they organised for their benefit. One person told us, “What is nice is that staff encourage me to communicate as I can spend a lot of time on my own.” Another relative told us, “I think they can be institutional at times, breaks times are always break times, it’s a high needs unit and people are waiting for a long time for things like going to the toilet, if they are in with other people, they can’t get to everyone straight away.”

The deputy manager told us, the numbers of staff and the staff skill mix, for example nurses, carers, domestic staff were based on dependency levels which were illustrated on the electronic monitoring systems. However, we found people’s assessed needs, used to calculate staffing numbers, were not always appropriately or accurately scored. The management team told us, they felt staffing levels were challenging for all staff groups. They told us, they had concerns about not being able to complete all the requirements the provider expected, due to the complex needs of people and staffing levels. The deputy manager told us, they did not have enough staff. Staff told us there were not enough staff to make sure staff were available when needed. Registered nurses were responsible for meeting the high and complex clinical needs of people they were caring for as well as managing the floor they were working on, and they were also expected to complete, review and update all care plans and risk assessments.

We observed some inconsistencies in staffing levels and staff skills in communicating with people. During activities there were enough staff to ensure people were able to engage in or actively watch what was going on so they were full participants. At lunchtime staff were available to serve meals and support people to eat, but at the end of the meal staff had all left the dining room when one person was still eating their pudding. The person had no way of calling for assistance after staff had left the dining room, staff did not return for a long period of time.

There were processes in place to recruit staff safely. The required checks had been completed to make sure staff were of good character to work with people. The duty rotas showed the numbers of staff the deputy manager told us were required on each shift, the suitable deployment of staff was a concern. The shortfalls found at this assessment confirmed staff feedback and concerns. The number of staff calculated as needed were based on inaccurate information, and did not take into account the time nurses spent with people providing complex clinical support. There had also been no consideration of the time staff needed to make sure care plans and risk assessments were accurate.

People were supported by staff who wore the appropriate personal protective equipment and washed their hands when appropriate.

Staff told us, they felt the service was clean and protected from cross contamination. Staff told us they followed personal protective equipment (PPE) guidelines wearing appropriate PPE when providing support to people.

The building was clean and odourless. There were water dispensers in the communal areas which looked unclean and stained with limescale. We mentioned this to the management team.

There were cleaning schedules in place to make sure areas of the service were cleaned regularly. Staff received training in infection control and there was a constant supply of PPE available.

People who required medicines to support them with their conditions did not have important information contained in their care plans. For example, a person who requires Parkinson's medicines did not have any information about the risks of not receiving these on time and how this could affect their well-being and risks to their care and support.

Staff told us, medicine competencies were not checked regularly. A staff member told us, ‘Oh no once it's done that’s it.' We reviewed competency records. One member of staff had 2 medicines competencies assessments on the same day. We observed staff completing the medicine rounds in the afternoon and the records show they had not completed medicine competency.

Medicines were not managed safely, processes in place had not always been followed and had not been effective. Provider audits had identified shortfalls and a lead nurse had been assigned to rectify these shortfalls, however, there continued to be concerns at this assessment. The medication room temperatures had not monitored effectively. The staff recorded temperatures, however, they were using the air conditioning remote control to record the temperature, which was turned off. The temperature in the room was high, this had not been identified and acted on. Medicines did not tally for all people we reviewed. There were medicines where there were more in stock than the system says there should be. The lead nurse did not know why this had happened, they suggested tablets had been carried over from the previous month, but this had not been recorded. There was a risk people had not received their medicines as prescribed. A person had their medicines administered covertly. Covert administration is when medicines are administered in a disguised format, such as in a person’s food or drink. A GP had completed an authorisation form; however, this was dated April 2022 and had not been reviewed since. Medicines were listed on the form as the medicines agreed to be given covertly by crushing them, new medicines had been prescribed and there was no record to agree if they were suitable to be crushed. The registered manager told us nurses discussed this verbally with the GP if new medicines were prescribed so there was no record of any changes and if these had been agreed. This did not follow the provider's process which stated, ‘Verbal orders from a doctor via the telephone (including instructions to add a medicine to the resident’s regime or amend a dose of a medicine) must not be accepted without the guarantee of accompanying written confirmation of the order.’