Gibson's Lodge Limited

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

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 provider was in breach of legal regulation in relation to people’s safe care and treatment and the ways people’s medicines were managed safely 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 based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Incidents were reported and investigations carried out There were some learning initiatives however information was not always fully completed. There was insufficient detail to demonstrate what learning had been identified or how it would reduce the risk of recurrence. Whilst there was some evidence of lessons learnt, these were not consistent and where they were identified, sufficient action had not always been taken to fully mitigate risks.

Governance and audit systems had not identified the issues we found during this assessment. There was a lack of oversight, monitoring and action which meant that risks to people's health were not adequately identified, monitored, or mitigated, leaving people at risk of avoidable harm.

The provider did not consistently demonstrate an effective learning culture. Staff did not always listen to or act on safety concerns, and incident records did not always show what learning had been identified or how this would reduce the risk of recurrence. Governance systems had not identified these issues, which limited leaders’ oversight of safety and risk.

The provider did not always work with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed.

Staff engaged with local health services, including district nurses and GPs, and arranged regular visits and reviews to respond to people’s changing needs.

Staff carried out pre-admission assessments and gathered information about people’s needs, preferences and risks. This supported decision-making and helped identify potential risks at an early stage. However, staff did not consistently act on the information they collected. They did not always implement care plans or risk assessments effectively, and they did not consistently take action to mitigate identified risks. This meant that risks were not always managed in a timely or effective way.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

The provider had safeguarding systems in place and staff had received safeguarding training. However, the impact of other failings including call bell response times and gaps in risk management exposed people to a possible risk of neglect. The provider did not recognise these risks because its governance and oversight arrangements were poor.

The provider did not consistently act on risks identified through assessments and care planning. Staff gathered information about people’s needs and risks; however, they did not always implement care plans or take action to mitigate risks in a timely or effective way. This meant risks were not always managed safely.

We also found concerns in relation to the application of the Mental Capacity Act. The provider had made a Deprivation of Liberty Safeguards (DoLS) application for a person who had capacity to make their own decisions. This placed the person at risk of unnecessary restriction and showed staff did not always understand their responsibilities in relation to people’s rights.

However, the provider had systems in place to report incidents and share safeguarding concerns with external agencies. Staff had received safeguarding training and were able to describe how to recognise signs of abuse and neglect. Whilst systems were in place, they were not always effective.

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.

Staff maintained care records and developed care plans to meet people’s health needs. Healthcare professionals were involved where required to support the management of risks. People told us they felt safe. However, records were not consistently accurate or complete. Staff did not always update care records to reflect people’s current needs. We identified gaps in key areas, including skin integrity, falls, nutrition and fluid intake, and weight loss.

Staff did not always complete monitoring records in line with people’s care plans. For example, one person’s safety checks were not fully completed, and another person’s monitoring records did not reflect their assessed needs. This meant staff did not always have reliable information to manage risks safely.

Staff did not consistently involve people and their relatives in reviewing care. While some people and relatives contributed to care reviews, this was not embedded across the service.

The provider did not ensure the environment supported people living with dementia. The environment was not fully designed in a way that supported people living with dementia. The service would benefit from improvements to make it more dementia friendly, including clearer signage and orientation aids to support people to navigate the building more easily.

There was no colour differentiation between areas or key points of interest, which limited opportunities to promote independent orientation for people living with dementia.

The provider had not implemented personalised visual cues, such as memory boxes, to help people identify their rooms. This meant the environment did not promote independence or support people living with cognitive impairment. Overall, the environment was not designed in a dementia-friendly way.

However, the provider maintained a clean and hygienic environment. Staff cleaned communal areas regularly, including bathrooms, and managed linen appropriately. The service was free from malodour.

The provider maintained equipment and safety systems. Staff carried out regular checks and servicing of fire safety systems, portable appliances, gas systems and legionella controls. Staff also completed checks on equipment, including hoists, wheelchairs, baths and window restrictors. Staff tested the fire alarm weekly and conducted regular fire drills.

The provider maintained the kitchen in a clean condition. Staff stored food safely and labelled opened items appropriately.

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. They did not always work together well to provide safe care that met people’s individual needs.

The provider did not ensure there were sufficient numbers of staff to meet people’s needs consistently. People and their relatives told us they experienced delays when requesting support, particularly with personal care, toileting and during mealtimes.

One person told us, “Staff are friendly but distant. I often have to wait a long time to get help and it takes a while for the bells to be answered.” A relative said, “Staffing is an issue. By the time my relative gets help their meals are cold. “And another relative told us, ”The staff do what they can, they’re all very busy” and another relative said” ”when you are ringing to come in or to leave, it takes forever for someone to come” .These concerns were consistent with feedback from staff, who told us staffing levels did not always meet people’s needs, particularly during busy periods and weekends.

Staff reported that staffing levels were often reduced during evenings and nights, which affected their ability to provide safe and responsive care. They told us people with higher levels of need were not always supported appropriately because staffing arrangements did not reflect the complexity of people’s need. During the inspection, delays in care delivery were observed, including delays in supporting people with personal care and assistance at mealtimes.

Although dependency tool and rotas indicated sufficient staffing levels, our observations showed people experienced delays in receiving care. This demonstrated that staffing calculations did not accurately reflect people’s needs in practice.

We observed that staff generally responded to call bells; however, people experienced longer waits during busy periods, such as mealtimes. The provider had not implemented effective systems to monitor call bell response times. We were unable to review call bell audits, as these were not made available despite our request. This meant the provider did not have oversight of response times or delays.

The provider’s governance systems were not effective in ensuring safe recruitment practices. We identified gaps in staff employment histories and found that references had not always been obtained from previous employers.

Managers had not ensured staff received regular supervision. Staff told us supervision was not taking place consistently. Where supervision did occur, it focused on tasks rather than staff development. This limited opportunities for staff to reflect on practice, improve skills and receive appropriate support.

Overall, managers had not ensured staffing levels, monitoring systems and workforce oversight were effective. This meant people did not always receive timely care and were at risk of unmet needs.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff had completed infection prevention and control training and demonstrated a clear understanding of their responsibilities. Staff told us they had access to the equipment they needed to maintain effective infection control.

We observed staff using personal protective equipment (PPE) appropriately. People had access to individual equipment, such as slings, where required to reduce the risk of cross-contamination.

The environment was clean and hygienic. Staff followed clear cleaning schedules and protocols to maintain standards of cleanliness and reduce the risk of infection

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.While some systems were in place for the storage and monitoring of medicines, the provider did not ensure these systems operated effectively in practice.

We identified multiple concerns in relation to medicines management, including inconsistent clinical monitoring, poor record keeping, unsafe administration practices and ineffective governance systems. These issues increased the risk of avoidable harm to people.

The provider did not consistently assess and manage risks relating to people’s health and medicines. Care plans in relation to medicines were not always accurate or up to date and, in some cases, contained conflicting information. This created a risk that staff followed incorrect guidance when supporting people.

Staff did not consistently carry out required clinical monitoring. For example, one person who required blood glucose monitoring three times daily did not consistently receive this support. Where high readings were recorded, staff did not always escalate concerns in line with care plans. This increased the risk of deterioration in people’s health.

The provider had not completed appropriate fire risk assessments for people using paraffin-based emollients, which are known to increase fire risk.

Staff did not always administer time-critical medicines at the prescribed times. Staff told us that only two staff were responsible for medicines administration across three floors, which led to delays. This meant people did not always receive their medicines when required.

Medicines administration was not always organised around people’s individual needs. For example, some medicines were scheduled at midnight without clear clinical justification.

Records showed that medicines were sometimes omitted because people were asleep. Staff had not adjusted administration times to reflect people’s preferences or routines.

Staff did not always have access to appropriate guidance for ‘when required’ (PRN) medicines. Some protocols were missing or not accessible at the point of administration, increasing the risk of unsafe or delayed use.

We found an expired eye gel in use. This posed a risk of reduced effectiveness or potential adverse effects.

Medicines administration records (MAR) did not always contain sufficient information for safe administration. For example, records for eye drops did not specify which eye the medicine was prescribed for, increasing the risk of incorrect administration.

Records did not demonstrate that covert medicines plans were regularly reviewed. For example, one person’s plan had not been reviewed since May 2023 and did not include a clear review date.

Best Interest decision records did not consistently include input from relevant healthcare professionals such as GPs or pharmacists. Records also did not clearly confirm whether medicines were safe to administer covertly or suitable for crushing.

For people with fluctuating capacity, records did not clearly evidence when covert medicines had been administered. These gaps increased the risk that medicines were not administered in line with prescribing guidance.The provider did not ensure safe systems for the management of controlled drugs.Records were not always complete or accurate. Some entries did not include the strength or formulation of medicines, making verification difficult where multiple formulations existed.

We identified inconsistencies in the recording of controlled drug destruction. The controlled drugs register index was out of date and did not reflect medicines recorded elsewhere in the register.

These issues increased the risk of errors and made it more difficult to identify discrepancies promptly.