Archived: Gloucester House

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in people’s care, support and outcomes.

The service was in breach of legal regulation in relation consent to care and treatment.

This service scored 42 (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 make sure people’s care and treatment were effective because they did not always check and discuss people’s health, care, wellbeing and communication needs with them.

Following the last inspection there had been an improvement in the detail in people’s care needs assessments. Care plans containing needs assessments, were long and provided intricate detail. Staff we spoke with told us they ‘very rarely’ read the care plans’ and relied on getting to know people, reviewing their main screen which provided an overview of assessed needs. However, we found this screen did not always contain the critical information of people’s needs and risks. People’s care records lacked required details around the management of risks associated with specific long-term conditions and how this impacted on their support needs. For example, when people were living with Parkinson’s disease, there was no information about how this could affect their mobility or swallowing. There was a lack of guidance in place around how staff should respond in the event a person sustaineda seizure or episode of choking and action to be taken if someone was choking was ‘to commence cardiopulmonary resuscitation (CPR) as soon as possible.’ This guidance does not follow national guidance and is not related to these individual needs.

The provider did not always plan and deliver people’s care and treatment with them, including what was important and mattered to them.

At our last inspection we found that the electronic system gave staff a task list which had been assessed as being required by the person’s care plan. However, there was not always guidance for staff about how to complete the required support and what to do if someone was unwell. For example, one person was living with epilepsy, there was no guidance about how a seizure may present and what action to take to keep them safe. We found this had not changed, despite being a requirement in the warning notice. We reviewed the same people’s risk assessments as the last inspection and found some people’s risk assessments had not been changed at all.

There had been referrals made to health and care services for additional support but there were no records of follow up information or implementation of advice in people’s care plans.

The provider did not always work well across teams and services to support people. They did not always share their assessment of people’s needs when people moved between different services.

We found instructions from healthcare professionals had not always been recorded in people’s care plans and risk assessments. Safe swallowing plans from the Speech and Language Therapy (SALT) team for people were not mentioned in their care plans, there was a risk staff would be unaware of safe swallowing requirements and people could receive meals/snacks/drinks prepared to an inappropriate texture causing significant harm.

The service did not establish effective communication and information sharing within the team. For example, there was no evidence that team meetings took place regularly, and that handovers were used to discuss what was needed effectively.

The provider did not always support people to manage their health and wellbeing, so people could not always maximise their independence, choice and control. Staff did not always support people to live healthier lives, or where possible, reduce their future needs for care and support. The registered manager had not always made sure staff had the skills and guidance to support people to remain healthy. Staff were not always provided with the most relevant and up to date guidance, for example, what to do when people were experiencing a seizure. Staff not having access to accurate guidance placed people at risk of not receiving appropriate support when they were unwell.

People’s care plans had not been completed with them to make sure staff knew how to support them in the way they preferred such as to promote their independence and choices.

People were referred to healthcare professionals when their needs changed. A relative told us, “I am absolutely delighted with it. It is perfect for my (relative). They are very proactive here, (staff member) noticed that (relative) had blisters on their arm. They sent photos to the Doctor, and (relative) was on antibiotics by the afternoon.”

The provider did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

People’s care plans had not been monitored to check they included accurate information and there was no process to monitor outcomes for people.

We found no evidence of records monitoring people’s epileptic seizures to establish possible triggers, trends or patterns. These increased risks of complications because of epilepsy.

Care plans did not always include people’s goals; the service did not monitor if goals were being achieved.

The provider did not tell people about their rights around consent or respect these when delivering care and treatment. There continued to be a poor understanding of the principles of the Mental Capacity Act 2005 (MCA), and there had been no improvement since the last inspection. Staff continued not to work within the principles of the MCA. When people had been assessed as having capacity, they had not signed consent forms pertinent to their care or agreement to their care plan.

Some people had been assessed as not having capacity, however, staff had not completed the required mental capacity assessment. There continued to be no evidence as to how the assessment of the person not having capacity had been made and in relation to what specific decision.

Deprivation of Liberty Safeguards (DOLS) referrals had been made without MCA assessments. Staff had applied for Independent Mental Capacity Advocates (IMCA) without assessing if people needed them, this did not follow the MCA guidelines. We were not assured training in the Mental Capacity Act 2005 was effective as staff and the registered manager had limited skills and knowledge in this area.