Gateford Hill 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. This is the first assessment for the service under this provider. This key question has been rated inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to safe care and treatment, nutrition and hydration, safeguarding, the environment and staffing.

This service scored 25 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There was not a proactive and positive culture of safety based on openness and honesty. Lessons were not learnt to continually identify and embed good practice. The registered manager was aware of the multiple concerns relating to staffing from multiple sources including people using the service, their relatives, CQC and staff but had not acted on any of these concerns. Staff became visibly upset when speaking with us and how they felt unheard. Staff said, “It’s pointless we raise concerns time after time with the registered manager and deputy manager before they left and nothing ever changes, it’s dangerous, we all feel totally helpless.” The registered manager had little oversight of the service; action was not always taken to improve the safety of the service. For example, we found a family had raised numerous concerns about their loved one’s care, little action had been taken to address the shortfalls in care, and the person continued to receive poor care. Failure to implement lessons learnt increased the risk of harm to people.

The service did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services. Whilst staff told us people were assessed prior to admission we found some people had limited care plans in place for care staff to follow. For example, a person who suffered from seizures had no care plan or risk assessment available to care staff. We also found a person who regularly became distressed had no care plan in place to support the person to manage their emotional needs. This meant staff had no guidance in how to safely support people. We found a person who lived with dementia had their care plan developed from a hospital discharge letter rather than seeking out information from their representatives who had previously cared for them. We also found staff did not always make referrals to external healthcare professionals when specialist input was needed. For example, we found staff had informed a social worker they had made a referral to an external service, we found they had not made this referral. Failure to ensure timely referrals were made to external healthcare professionals increased the risk of avoidable harm to people.

The service did not have robust systems in place to protect people from the risk of abuse. We found staff did not always recognise incidents as safeguarding concerns. This meant people were at an increased risk of abuse or neglect. For example, we observed four incidents during the assessment which we reported to the Local Authority safeguarding team. Staff failed to recognise any of these incidents as neglect. This exposed people to the risk of ongoing abuse. Furthermore, we observed people to be restricted to their beds without reason. Staff explained that they rotated which people they got out of bed as they couldn’t support all people who required support to get out of bed each day. Staff failed to recognise this as restrictive practice and as a safeguarding concern. Not all incidents were reported to the Local Authority safeguarding team and CQC. Failure to report safeguarding concerns to the relevant parties was not in line with the provider’s own policy and exposed people to the risk of ongoing safeguarding concerns.

The provider and registered manager did not always ensure staff supported people safely. We found staff did not have clear guidance in place to ensure people were supported in a safe way and according to their needs. For example, a person who required support with their mobility needs had inaccurate information in their care plan. We also found a person with mental health needs had no positive behaviour support plan in place despite frequently becoming distressed. We found a person to have bed rails in place, however there was no risk assessment in place to determine if these were safe to use. The lack of risk assessments and care plans meant staff had no guidance or inaccurate guidance to ensure they could support people safely. A person told us they were provided with equipment to use to mobilise safely around the home, but they had fallen as there were no staff available to support them to use it safely. Another person we spoke with said, “Sometimes only one staff member comes to help me, and I really need two, so my turns get missed.” Failure to ensure risks were managed placed people at risk of avoidable harm.

Risks associated with the environment were not managed to protect people from the risk of harm. We found many large heavy wardrobes to be unsecured from walls in people’s bedrooms. This meant large heavy wardrobes could tip or fall, which increased the risk of harm to people. We also observed radiators covers in various places throughout the building to be loose and broken. We found oil-filled radiators in people’s bedrooms which were very hot to touch and posed a risk to people with sensory and cognitive impairments. There was a lack of risk reduction measures in place which placed people at an increased risk of harm. We found areas of the home were in a state of disrepair. An area outside a person’s bedroom had crumbing plaster and mould present. This posed a risk to people. There were only two working shower rooms for the building with all others being unusable. There was no risk assessment in place to determine whether people’s needs had been considered when refurbishing all the shower rooms. The home was not secure as doors to the car park were open without being alarmed. Some people living at Gateford Hill were not able to leave the home alone as this placed them at risk of harm. Lack of alarms to unlocked doors meant people could leave the service without staff being aware. This placed people at an increased risk of harm. The provider was receptive to our feedback and acted, they acknowledged the improvements required and demonstrated a commitment to people to improve the safety of the service.

There were insufficient staff on duty to ensure people received timely care and support and their safety maintained. We found on several occasions there were no staff in communal areas or upstairs despite people being present in these areas. We found multiple people in an unkempt state with their food and drink left out of their reach with no staff available to support them. People and their relatives had raised several concerns about staffing levels at Gateford Hill to the registered manager with no action being taken to review and increase staffing numbers. The registered manager failed to acknowledge these concerns or escalate them internally. This placed people at an increased risk of avoidable harm. All the people and the relatives we spoke with told us staffing was an issue. A person we spoke with said, “This place needs a lot of staff and there’s not enough here. No one has time for you.” Another person said, “Personally, there’s not enough staff, as they can’t come quickly. At night it’s worse.” A family member we spoke with said, “We have to help my [relative] to bed. Last weekend they only had 1 carer per unit at night and a shared nurse. It’s downright dangerous.” We raised staffing concerns with the provider who acted immediately, they reviewed the staffing numbers and increased the staffing levels to ensure people were safe at Gateford Hill. Staff were recruited safely.

Infection and prevention control measures in place were not effective. Parts of the home were in a state of disrepair meaning it could not be cleaned effectively. We found a wall with crumbling plaster and chipped door frames and skirting boards. We found equipment in use, such as a falls crash mat, to be dirty. We observed a shower room which was in use to be covered in mould. We also found a shower chair which was rusty and could not be cleaned effectively. Internal processes had not identified these areas, or where they had, action had not been taken to rectify and address the issues. We found carpets to be stained. People told us they felt staff worked hard to clean the home. Failure to ensure effective infection and prevention control measures were in place placed people at an increased risk of harm.

Medicines were not managed safely. We found topical medicines were not stored safely. We found topical medicines which were accessible and unsecured in people’s bedrooms. This placed people living with dementia at risk of harm if they had access to these products and ingested them. We found topical medicines were not always dated with an open date. This meant staff did not know if these were safe or effective to use. People did not always receive their prescribed medicines on time. We found a person who required time-specific medicines received these late on 3 occasions within a 3-day time period. A person we spoke with said, “I asked for a pain killer last week three times and they just never came back.” Failure to ensure medicines were managed safely placed people at an increased risk of harm.