Archived: Gloucester House

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 requires improvement. At this assessment the rating has changed to 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 people’s safe care and treatment.

This service scored 38 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

Staff told us the management team had not told them the outcome of the last inspection and were told the only improvement needed was the ‘paperwork.’

We were not assured that the provider had taken the opportunity to learn from the warning notices issued in November 2024 in relation to safe care and treatment, to make improvements. Risk assessments were still lacking detail and had not addressed the risks to people and staff.

The provider had introduced a new 10 at 10 meeting daily to provide an opportunity for heads of department to discuss incidents/concerns/good practice however, staff told us that they had not been given the opportunity to feedback following incidents being raised. Although the records of incidents we reviewed were improved with more detail, staff were not told of an outcome of investigations.

The provider 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.

People’s safety was not robustly monitored or managed. Risk assessments used to populate people’s hospital passports were not always adequate, and some risks had not been assessed appropriately, reviewed or mitigated. Staff knew people well but there was a risk that people could come to harm when being supported in hospital by staff who did not know them well. There was a risk hospital staff would not have accurate information about people’s care needs and support.

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 did not always share concerns quickly and appropriately.

The registered manager had not recognised and raised safeguarding concerns as required. A relative told us their family member had stated they had their head pushed back by another person. This had been logged as a complaint and not raised as a safeguarding concern at the point the concern was raised.

Staff told us they had raised incidents to the deputy manager, who had left the service recently, regarding potential abuse. We could not find evidence these had been raised with the local safeguarding authority.

The provider had requested lessons learnt and safeguarding to be added to the agenda for all daily 10 at 10 meetings for heads of department, wider staff and relative meetings. However, we reviewed meetings since March 2025, and this had not been actioned.

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

Processes in place were not effective in identifying and providing guidance to manage risks and keep people safe. There was no guidance in place for staff to recognise signs and symptoms of health conditions. Risk assessments contained limited guidance for staff to provide support to people with complex health needs and conditions. There was an over reliance on nurses to support care staff, however, nurses time was limited, and they were not always available to support staff when needed.

When risk assessments had been completed the guidance was clinical and more relevant to the nurses. For example, when people received their nutrition through a tube and were nil by mouth.There were guidelines to maintain the tube but not about providing mouth care, there was a risk of people choking or aspirating if not completed safely.
Risk assessments were not always personalised and did not link to each other to give an overall view of people’s risks. When people had equipment in place to support their airway, the risk assessments were the same, even though people’s needs were different.

There was limited guidance about how the person displays they are unwell and when to call the emergency services.
Risk assessments were generic and seen recorded in other people’s care records, though people did not have the same care needs or risks. Documents used standard phrases produced by the electronic system and were not specific to people’s actual needs and risks. For example, diabetes care plans stated what to do if the person had low blood sugar and was alert. However, there was no guidance for when people were not alert and may need immediate medical intervention.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The registered manager told us, there were enough domestic and maintenance staff, to keep the environment safe for people.

We did not have any concerns in relation to the safety of the environment. The service was clean and there were no obvious hazards around the building. People were cared for in a safe and clean environment that was designed to meet their needs. The corridors and communal areas were spacious, people who used a wheelchair had sufficient room to do so safely. There was a range of equipment to help people move around their home such as handrails and hoists. There were several different areas where people could sit and we observed people using these spaces.

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

There were no effective systems in place to supervise and train staff to make sure they could support people safely. The registered manager had recorded staff meetings as staff supervisions. We found the meetings were the only supervisions recorded, there were no individual supervisions recorded. Staff had not been given the opportunity to discuss their practice and ongoing development. The trained nurses had not received clinical supervision to make sure they were up to date in their practice and were competent. Most care staff had not had any supervision recorded for 2025. There was a risk that staff would not be effective in their roles to keep people safe.

Staff told us, “I can’t remember when I last had a supervision or one to one. That tells you how long ago it was.” Staff told us they felt supported by one another but not by the management or provider.

At the last inspection there were not enough staff to support people safely. At this inspection people and relatives told us they thought there were enough staff, and they came quickly when they rang their call bell. However, at this inspection the number of people staff were supporting had reduced to 31 and the staff employed had not been reduced. We observed staff in all areas of the service supporting people when required.

Staff had been recruited safely, the required checks had been completed to make sure staff were of good character.

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.

People were supported by staff who wore the appropriate personal protective equipment (PPE) and washed their hands when appropriate when providing personal care. However, staff were observed not to be wearing aprons when serving or assisting with meals.

Staff told us, they felt the service was clean and people were protected from cross contamination. Staff told us they followed PPE guidelines wearing appropriate PPE when providing support to people.

The building was clean and odourless. There were cleaning schedules in place to make sure areas of the service were cleaned regularly. Staff received training in infection control and there was a constant supply of PPE available.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning. At our last inspection medicines were not managed safely and this continued at this inspection. There continued to be no information about how people’s time sensitive medicines affected their condition such as Parkinson’s disease, where not receiving their medicines on time could affect their mobility. Records showed people were consistently receiving their Parkinson’s medicines late, these medicines had been given as part of the general medicine round, there had been no attempt to give the medicines at the time prescribed.