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Archived: Gorseway Care Community Requires improvement

The provider of this service changed - see new profile

Inspection Summary

Overall summary & rating

Requires improvement

Updated 28 April 2018

This unannounced inspection took place on 8, 9 and 12 January 2018. The inspection was bought forward due to information of concern we had received about the safety and management of the home, and the care provided to people.

After this inspection CQC was made aware of a person’s death at this location which has been brought to the attention of the police and local authority.

Gorseway Care Community is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Gorseway Care Community can accommodate up to 88 people, some of whom live with dementia. This can be provided across two houses, one of which can accommodate up to 28 people and the second can accommodate up to 60 people. The provider was not using the house which could accommodate up to 28 people. The regional manager told us they would only provide support to up to 50 people in the building currently in use. Accommodation in this building was provided over two floors one of which was for people living with dementia and called ‘Memory Lane’. At the time of this inspection there were 42 people living in the home.

At the time of our inspection visit there was not a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. A new manager had been appointed and has submitted an application to CQC to become the registered manager. Throughout the report we refer to this person as the manager.

The last inspection of the service was on the 7 and 8 March 2016 and we rated this service as overall “Good”. At this inspection we found the overall rating showed improvements were required and the extent to which people were being kept safe by the service had deteriorated and was now rated as inadequate.

The information available to guide all staff, including new and temporary staff on how to support people safely and minimise risks to people were not always accurate, sufficiently detailed and consistent. Actions identified in risk management plans were not always followed by staff which placed people at risk of not receiving safe care and treatment.

The provider had used a dependency assessment tool to calculate the staffing levels in the home. Whilst this showed sufficient staff were available to meet people’s needs, we found this was not always the case in practice. During the inspection the provider told us about the recent staffing changes they had made and were confident these would achieve improvements for people. However, following the inspection we received information from the provider in response to concerns raised which showed these changes had not been made.

Care plans were not in place to guide staff as to how people should be supported with their medicines. Risk assessments were not in place for medicines which pose an increased risk to people such as those to thin their blood and we found errors had occurred. When errors had been identified the actions taken to address the error was not always recorded to show how this had been addressed for people’s safety.

Systems were in place to support learning and improvements when things went wrong. There was evidence to show when these were used improvements had taken place. However, this was not always consistent and incidents were not always identified and followed up to ensure the cause was established to enable learning to take place.

People told us they felt safe living at the home. Staff understood their responsibilities to protect people from abuse and referrals had been made to the local authority when incidents or allegations occurr

Inspection areas



Updated 28 April 2018

The service was not safe.

The information available to guide all staff on how to support people safely was not sufficiently detailed or consistent. Actions identified in risk management plans were not always followed by staff. This placed people at risk of not receiving safe care and treatment.

There were not always sufficient, suitably experienced and competent staff available to meet people’s needs at all times.

Records associated with the safe management of people’s medicines were not always available or completed to guide staff and support safe administration.

Some systems were in place to identify learning and improvements when things went wrong. However not all incidents were identified or acted on to enable this system to be fully effective.

Staff had the knowledge to identify safeguarding concerns and acted on these to keep people safe.


Requires improvement

Updated 28 April 2018

The service was not always effective

People’s needs were assessed and the provider used evidence based practice to inform their policies, procedures and staff training.

Staff completed on-going training to develop their knowledge and skills to support people effectively with their needs.

People's records did not always evidence their consent or decisions made in line with the principles of the Mental Capacity Act (2005). Deprivation of Liberty Safeguards (DoLS) information was not available in people’s care plans to guide staff on the appropriate support for people with a DoLS in place. There was a risk people’s legal rights would not be upheld.

People were provided with good quality food. Some people may benefit from more prompting to eat and drink sufficiently.

People were supported with their healthcare needs.


Requires improvement

Updated 28 April 2018

The service was not always caring

People told us they were treated respectfully by kind and caring staff.

Staff did not always have sufficient time to spend with people and information was not always available about people’s safety needs to promote a caring approach.

People received support with personal care in privacy.

The provider promoted the principles of equality, inclusion and diversity through policy, procedures and staff training. Staff showed an awareness of people’s diverse needs and a commitment to challenge discrimination.

Opportunities were available for people and their supporters to express their views about the care and treatment provided in the home .


Requires improvement

Updated 28 April 2018

The service was not always responsive

People’s care plans did not always reflect their personalised information or show how people and their representatives had been involved in decisions made about their care. Work was in progress to update care plans with this information.

Activities, events and entertainment were provided for people. This included small group and one to one activities.

A complaints procedure was in place and available to people and their relatives. People’s complaints were responded to in line with the procedure and action was taken to address concerns raised.

The service was not always responsive


Requires improvement

Updated 28 April 2018

The service was not always well-led

A quality assurance system was in place and information from audits was used to inform a central action plan to drive continuous improvements.

The clinical governance system was not always effective because incidents were not always identified by staff or reviewed by the manager to show the actions taken to manage risks and drive continuous improvements.

There was new management team in place and feedback from staff and people was mostly positive about the leadership of the home. Some time was needed for the team to develop and embed the changes and improvements they had planned.

Although quality assurance survey results were not available at the time of our inspection. People, their relatives and staff were engaged through meetings to give their views on the service which were responded to by the provider.