Gloucestershire House - Care Home with Nursing Physical Disabilities

Ratings

• Overall

  Requires improvement

• Safe

  Requires improvement

• Effective

  Requires improvement

• Caring

  Good

• Responsive

  Good

• Well-led

  Requires improvement

Our view of the service

Dates of assessment: 01 and 15 July 2026. Gloucestershire House - Care Home with Nursing Physical Disabilities is a care home that provides nursing and residential care and support for up to 30 people. Support was provided within one adapted building. The service consisted of five separate lodges within the building, each of which housed six people and had its own name and set of allocated care staff. There were 29 people living at the service at the time of our assessment.

Care and support were provided to people living with physical disabilities as a primary care need, however in some cases people also lived with learning disabilities as a secondary care need. Due to this reason, we assessed the care provision under Right Support, Right Care, Right Culture.

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. 'Right support, right care, right culture' is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

While people’s feedback about living at the service was largely positive, we identified concerns relating to the safe management of risks, medicines, infection prevention and control, staffing and consent. We also identified significant shortfalls in relation to governance systems.

We found 2 breaches of the legal regulation relating to safe care and treatment and good governance.

Staff treated people with kindness, dignity and respect, and people were involved in decisions about their care and support. We observed positive interactions between people and staff throughout the assessment. We found staff knew people well, understood their preferences and promoted their independence, choice and control. People had access to a range of activities, community opportunities and healthcare support, and there were examples of innovative approaches to promoting independence and inclusion. However, systems to identify, assess and manage risks were not always effective. People’s care plans and risk assessments did not consistently provide staff with sufficient guidance to manage identified risks safely. We found shortcomings in environmental risk management, medicines management, infection prevention and control practices, consent documentation and aspects of staffing and staff development. Although staff demonstrated good knowledge of people and leaders acted promptly on some of the concerns raised during the assessment, these issues meant people could not always be assured of consistently safe care.

The service continued to demonstrate good working practices with healthcare professionals, supporting people to maintain relationships, participate in their communities and pursue meaningful goals. However, governance and quality assurance systems were not robust enough to identify and address concerns in a timely way. Audits, monitoring processes and oversight arrangements had not consistently identified or addressed without delay the issues found during this assessment.

Overall, although people experienced compassionate and person-centred care, improvements were needed to governance, oversight and risk management to ensure people consistently received safe, high-quality care and support.
 

People's experience of this service

People’s experiences of living at Gloucestershire House - Care Home with Nursing Physical Disabilities was mixed, although feedback was positive overall. People described the service as friendly, welcoming and supportive, valuing the friendships they had formed and the opportunities to maintain their independence and make choices about their everyday lives. One person told us; “I love it here, don’t think you could get a much better place than here,” whilst another said; “It feels good here. I’ve made friends.” Relatives also described the service as; “Really good”, “Great”, and “Excellent.”

People told us they felt safe living at the service and knew who they could speak to if they had concerns. Staff were described as kind, caring and respectful. We observed positive interactions between people and staff, and people told us staff listened to them, respected their privacy and sought their consent before providing care. One person said; “Staff do listen and I feel that I can talk things out with them.” Relatives frequently described staff as caring and supportive. A professional told us; “A particular strength of Gloucestershire House is its commitment to ensuring that residents are fully involved in decisions affecting their lives. (A person I am supporting) has always been encouraged and supported to participate in care planning, reviews, and professional meetings, with their views and wishes clearly reflected in the process.”

People enjoyed taking part in activities such as music, drumming, bingo, wheelchair dance, shopping trips and outings in the community. Many valued the support of personal assistants to help them maintain relationships and access activities that mattered to them.

However, concerns were shared about staffing levels and responsiveness, with some people and their relatives reporting they occasionally had to wait for support. Some relatives shared concerns about communication, reduced opportunities for activities and therapy, the loss of experienced staff and the absence of a deputy manager affecting continuity and communication. They felt these changes had impacted some people’s experiences of care.

Despite these concerns, many people continued to describe the atmosphere as friendly and inclusive and told us they enjoyed living at the service and felt part of a supportive community.