Gloucestershire House - Care Home with Nursing Physical Disabilities

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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to people’s safe care and treatment, the ways people’s medicines were managed and governance at the service.
 

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.

The provider did not always have a proactive and positive culture of safety. Lessons were not always learnt to continually identify and embed good practice.

Systems and processes to capture and share learning were in place and shared with staff in meetings, through memos or supervisions.

A lessons learned log was in place to capture learning as identified arising from some incidents, accidents, concerns, complaints and safeguarding. Individual incident and accident records were completed and reviewed by the management team; however, there was no evidence of a formal process for analysing these events collectively to identify themes, trends, patterns, or emerging risks. This limited the provider's ability to demonstrate effective oversight and the use of learning to support continuous improvement.

The lessons learned log did not demonstrate how identified learning was monitored or reviewed, despite this being a required element of the process. While there was some evidence that the registered manager reviewed the log on a monthly basis, records did not always clearly show how lessons learned were tracked, evaluated, or used to drive improvements within the service.
 

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Records showed the service was supported by a multidisciplinary team of healthcare professionals. There were established links to local services, including a GP surgery that visited weekly or more frequently as required, tissue viability support and speech and language therapist support. Records showed people had their health and medication regularly reviewed.

People told us they had good access to healthcare professionals, and care plans included advice or recommendations made following a review.

A professional working with the service described staff at Gloucestershire House as caring, compassionate and committed to meeting residents’ highly complex needs. However, they noted communication could be improved upon.
 

Safeguarding concerns were reported internally and externally and were subject to investigation. However, there was no effective oversight mechanism in place to monitor safeguarding activity, track outstanding actions, or ensure timely progression of investigations. For example, in one safeguarding incident involving other agencies, there had been a delay in obtaining an update from one agency regarding the outcome of their investigation. This resulted in delays in providing updates to the people involved. Action to address this issue was initiated following conversation during our inspection.

People told us they felt safe living at the service. They told us; “I feel secure and safe, better than the other places I’ve been to and I’ve made friends.” People’s relatives confirmed this. Staff knew how to raise safeguarding concerns and safeguarding was part of staff and resident meetings.

The provider had oversight of Deprivation of Liberty Safeguards (DoLS) authorisations and was commencing work to review these in response to the recent changes following court ruling.
 

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People had risk assessments in place, however when risks were identified, care plans did not always provide guidance for staff on how to recognise and reduce the risks. For example, plans in relation to urinary catheters did not include guidance for staff on how to recognise the signs of an infection.

Some people had been assessed as being at risk of skin damage. However, not all care plans were completed to reflect the assessed risks, and not all staff were confident about correctly setting people’s pressure relieving equipment.

People at high risk of choking had detailed care plans in place and senior staff carried out formal checks at mealtimes to ensure people received the correct diet based on their requirements.

Staff knowledge of people and any associated risks with their support needs was good and the provider started to take action to address some of our findings during the assessment. However, the shortfalls identified above placed people at risk of harm.
 

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Regular checks on the environment including fire safety, legionella and lifting equipment were carried out. However, we found actions required in response to identified risks related to the safety of the environment were not always robustly followed up.

We identified shortfalls in relation to environmental risk management. For example, risks related to outlets where water temperature were running higher than 43 degrees were not robustly assessed and mitigated. We also identified a fire risk assessment identified actions that remained overdue beyond their May 2026 completion date. This placed people at risk of harm.

A Legionella risk assessment identified remedial actions; however, no action plan was in place to demonstrate required actions, timescales, or progress monitoring. Although the provider advised that works had been brought forward, the absence of documented oversight limited assurance that identified risks were being addressed without delay.
 

We received mixed feedback in relation to staffing levels and their responsiveness, including people experiencing delays in receiving support. The service used a dependency tool to determine staffing levels and management undertook daily walkarounds that included testing call bell responses. However, these had not been effective at identifying people’s concerns and making improvements. The provider advised that night staffing levels had already been increased following feedback received, exceeding the levels indicated by the dependency tool.

We received concerns around the gender mix of staff and the need to ensure people's individual preferences were respected. One person told us, “They need a better mix of male and female staff. We do need another female staff member in my lodge. There are not as many agency staff used now. I spoke up for everyone about the high agency use and it did get better.” This was shared with the provider.

One staff member said, “When we have full staff, people get to go out more and do what they want. I do think some people miss out on going out because I have to make sure we have enough [staff]. We are quite complex; we have lots of people who need hoisting with 2 staff. People don’t want to wait for the toilet for example.”

Staff did not always receive regular supervision although staff told us they felt supported and listened to.

Systems were in place to ensure staff received mandatory training and to monitor training compliance. However, records showed some gaps in required training. During the inspection, the provider began taking action to improve this. Records also did not demonstrate whether staff had received training specific for supporting people with acquired brain injury (ABI) and cerebral palsy. People felt that staff had the necessary training to support their needs, and, in the main relatives confirmed this, however some relatives commented that newer or less experienced staff would benefit from additional training and support.

Improvements were needed to systems to ensure staff were recruited safely. The reason for leaving and conduct in previous care roles was not consistently verified and recorded for all roles involving children or vulnerable people.
 

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The environment was clean and odour free. Information related to infection prevention control (IPC), including visual prompts regarding correct hand-washing techniques was displayed around the service.

We observed on the first day of the site visit that people’s personal shower or toileting slings were stored and dried communally in the shared bathrooms, this increased the risk of cross contamination. This was addressed during the inspection.

Regular IPC and environmental checks were carried out by a person living at the service in a voluntary role. Although actions were identified, records were not sufficiently detailed or complete and did not consistently demonstrate that these had been addressed by the registered manager.

Feedback from people indicated they were satisfied with the cleanliness of their environment. Comments included; “It’s very clean here, everywhere is nice and clean” and “My room is lovely and clean, yes it’s all cleaned well.”
 

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Medicines, including controlled drugs (CDs), were stored securely and at appropriate temperatures. However, records relating to the destruction of controlled drugs were not always completed accurately.

People received their medicines as prescribed.
Where people were prescribed medicines to be administered on a "when required" (PRN) basis, guidance was not always available to support staff to administer these medicines consistently and safely.

Information to monitor and manage the side effects of high-risk medicines such as anticoagulants was not recorded in care plans. This meant staff may not have had access to all the information required to support people safely.

Clinical staff from the local GP practice carried out regular medicine reviews. The service had a medicines policy and processes for reporting and investigating medicine incidents. Staff completed medicines audits; however, these had not identified the recording shortfalls and gaps in medicines documentation found during our inspection. This meant governance systems were not always effective in identifying and addressing issues relating to medicines management.