Gairloch Residential Care Home

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 regulations in relation to safe care and treatment and staffing.

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.

Lessons were learnt to identify and embed good practice. Suitable arrangements were in place to record, investigate and respond to any concerns and complaints raised with the service. There were procedures in place to record incidents and accidents. The provider and manager reviewed the latter to identify where actions were needed, for example, medicine errors. The last recorded complaint was February 2024.

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.

The provider adopted assessments of need by trusted assessors. A trusted assessor is a professional who is authorised to conduct assessments on behalf of an organisation to determine a person’s needs for care and support

The ‘red bag’ initiative was in place. This is a hospital transfer pathway to help improve care and discharge outcomes for people by ensuring key information and personal items travel with them to the hospital and when they return back to Gairloch Residential Care Home.

The service collaborated with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect.

People and their relatives considered themselves and their family member to be safe. People using the service and their relatives told us, “Yes, I feel safe, windows don’t open easily, and the doors are secure” and “[Person who uses the service] is safe here.”

Staff were able to tell us about the different types of abuse and what to do to make sure people were protected from harm. Staff told us they would escalate any concerns to the provider or manager. The manager was aware of their responsibility to notify us and the Local Authority of any allegations or incidents of abuse. Staff had completed appropriate safeguarding training.

The provider did not ensure all risks to people’s safety and wellbeing were identified or provided enough detail as to how these should be mitigated. Staff did not always provide care to meet people’s needs that was safe.

We identified concerns with fire safety whereby people could be placed at potential risk of harm in the event of a fire emergency. The Personal Emergency Evacuation Plan [PEEP] folder was not accurate or up to date. No records were available to demonstrate regular fire drills for both day and night staff were being conducted. There were no trained fire wardens on each shift to ensure the safe evacuation of people in the event of a fire, by leading and coordinating the evacuation process. Following our assessment the provider confirmed fire marshal training was conducted in April 2025 for the manager and 2 additional members of staff employed at the service.

We observed 2 members of staff perform unsafe moving and handling practices whilst supporting a person to mobilise and to prevent them from falling. Staff repeatedly grabbed either their arms and or their hands to stabilise the person and to prevent them falling. This technique is unsafe, can hurt and cause injury such as bruising.

Not all risks to people’s safety and wellbeing were identified and recorded, particularly where people were at nutritional and hydration risk, where they had a catheter in place or had developed a pressure ulcer.

The provider controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. However, a relative raised concerns about the continuous lack of hot water within their family member’s bedroom. Although the provider and manager were aware of this and a new water tank had been installed, action to rectify the problem in the longer term was not being managed in a timely manner and required an effective resolution. We ran the hot water tap in this person’s room during our assessment and found there was still no hot water available. This was brought to the attention of the manager for resolve. People and relatives did not express any concern in relation to the safety of the environment.

Routine environmental and equipment checks were completed to ensure the premises were safe. For example, safety checks were completed relating to the service’s electrical and gas installation system, portable appliances throughout the service and fire safety equipment checks. Specialist or adaptive equipment was made available for people’s use to ensure their needs were met.

People had access to an outside space that was secure and safe.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development.

People’s and relatives’ comments relating to staffing were variable. A person told us they did not always have their comfort needs met in a timely manner. They told us, “Sometimes they [staff] come too late, and I have gone in the pad. That makes me feel dreadful and it is degrading, I have to keep calling and calling [staff].” Another person told us, “Not enough staff.” Relatives confirmed what people told us and expressed concerns about the lack of appropriate meaningful interactions by some members of staff with people using the service.

We were concerned about the deployment of staff as 1 of 2 communal lounge areas were often left without sufficient staff support. Interactions by staff were repeatedly observed to be minimal and task focused. We were concerned about night staffing levels, particularly in the event of a fire emergency. There were 2 members of staff rostered each night between 20.00 and 07.30. However, Personal Emergency Evacuation Plans [PEEP] recorded all but 3 people using the service were likely to panic during an evacuation and required the assistance of 1 or 2 members of staff to safely evacuate.

Observations of staff’s practice did not provide assurance staff were skilled and competent to effectively apply their learning in their everyday practice. Although staff had received ‘practical’ moving and handling training, not all staff’s practice was safe. There were people at the service who were living with dementia, but not all staff demonstrated and delivered effective person-centred dementia care and support. Not all chef’s employed at the service had received training relating to textured diets for people with dysphagia [difficulty swallowing] nor were they aware of the guidance relating to the International Dysphagia Diet Standardisation Initiative [IDDSI] framework which was introduced in 2019. The manager told us the staff member responsible for facilitating activities for people using the service had received appropriate training for their specific role. However, during our assessment there was minimal evidence of their training being put into practice.

Staff had not received regular formal supervision or an annual appraisal of their overall performance, and this included the manager.

The provider had an effective recruitment and selection procedure in place. However, where staff had been promoted to a senior position, there was no evidence of them having completed an induction to this role. These are usual procedures to ensure staff have the information and guidance necessary to prepare them for their new role. No information was recorded to demonstrate the progress and satisfactory completion of an employee’s performance and probation review during their initial employment period.

The provider did not always manage the risk of infection. We observed toilet brushes left sitting in water. Although the water was not dirty, this practice can promote bacteria growth and is considered poor hygiene practice due to the potential infection risks posed. Several toilets were observed to have unsightly deposits built up in the toilet bowl. Dirty toilets can conceal bacteria, viruses, and other pathogens that can cause infections, especially for vulnerable people using the service. This is poor practice and is essential for maintaining hygiene and preventing cross contamination. People were not routinely given the opportunity to wash their hands or for antibacterial wipes to be used prior to and after mealtimes. Staff were clear about their roles and responsibilities to ensure people were protected by the prevention and control of infection arrangements at Gairloch Residential Care Home. Staff had access to policies and procedures on infection control and had sufficient Personal Protective Equipment [PPE]. Staff were observed using Personal Protective Equipment [PPE] appropriately and when required.

The provider made sure that medicines management was safe and met people’s needs. Staff were observed to administer people’s medicines appropriately and in line with current guidance. The medication rounds were evenly spaced out throughout the day to ensure people did not receive their medicines too close together or too late. Observation of staff practice showed staff undertook this task with dignity and respect for the people being supported.

Medicine records were maintained to a good standard, and Medication Administration Records [MAR] demonstrated people received their medicines as they should and in line with the prescriber’s instructions. The service ensured people's behaviour when anxious and distressed was not controlled by excessive and inappropriate use of medicines.

Staff confirmed they had received appropriate medicines training and had their competency assessed at regular intervals to ensure their practice remained safe when supporting people with their medicines.