Gwendolen Road Care Home

Updated 14 February 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

Inspection team

This inspection was completed by 2 inspectors and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Gwendolen Road Care Home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Gwendolen Road Care Home is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided. At the time of our inspection there was a registered manager in post.

Notice of inspection

The service was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 4 people who used the service and we observed staff interaction with people, to help us understand people’s experience. We spoke with 6 relatives about their experience of the service. We spoke with the provider, the registered manager and nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We also spoke with the acting manager, supporting manager, 2 senior support workers, 3 support workers, a cleaner and cook. We spoke with 1 visiting health care professional. We reviewed 8 people’s care records and 3 staff files and a variety of records relating to the management of the service, including audits and checks and medicine records.

Updated 14 February 2023

Gwendolen Road Care Home is a residential care home providing the regulated activity of personal care for 14 people in one adapted building. The service provides support to people who primarily have a learning disability or a long-term mental health condition. At the time of our inspection, there were 12 people living at the service.

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

People’s experience of using this service and what we found

Right Support: Improvements had been made since the last inspection and people were receiving the right level of care and support, they had been assessed as required. Most care plans had been reviewed and plans were in place for this to continue. Guidance for staff about how to meet people’s individual needs was detailed and up to date. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Right Care: Care staff knew people and what was important to them, including their routines and preferences. Staff had received refresher training and opportunities to discuss their work, training and development and this was ongoing. Improvements had been made and were ongoing, to ensure people were enabled to achieve positive outcomes. Social inclusion was promoted, enabling people to be a part of their local community. Staff were observed to be kind, caring and respectful.

Right Culture: The culture of the home was changing, improving and cohesive. The staff and management team were observed to be working together to promote people's safety and wellbeing. The provider had made changes to the management team and further improvements were planned. Staff were positive about the improvements made and felt well supported. Overall, relatives were happy with the service being provided to their loved one. They reflected on the improved decoration and cleanliness in the last few months.

Staff were recruited safely and received an induction before working with people independently. People received their prescribed medicines safely. However, improvements were required in the systems and processes and audits to ensure medicines management systems were safe. The provider took immediate action to improve this.

Safeguarding systems and processes were in place to protect people from abuse and avoidable harm. The provider had acted when safeguarding incidents had occurred.

Improvements had been made to the health and safety of the environment, premises and equipment. This included infection prevention and control measures. People lived in a home that was clean and hygienic.

People received a choice of meals and drinks and their dietary needs and preferences were known by staff, but not recorded in the kitchen. However, the provider took immediate action and made this information available.

People were supported to access health services. Staff monitored people’s health and worked with healthcare professionals to support people’s health and well-being.

People were supported with their individual communication needs. This included supporting people in their preferred language, which was not English. Care and support provided by staff, respected people’s different cultural needs, preferences and routines.

Improvements had been made and were ongoing in how the service was managed. New and improved systems and processes had been developed and the provider had an action plan to further drive improvements at the service. Further time was required for these processes and improvements to become fully embedded and sustained. Whilst there was senior management oversight and leadership, roles, responsibilities, and accountability, all needed further review. Audits and checks on quality and safety needed further improvements.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was inadequate (published 29 November 2022) and there were breaches of regulation and enforcement action was taken. At this inspection we found improvements had been made, however, the provider remained in breach of 1 regulation.

This service has been in Special Measures since 29 November 2022.

During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

The overall rating for the service has changed from inadequate to requires improvement based on the findings of this inspection. We have found evidence that the provider needs to make continued improvements. Please see the safe, effective, responsive and well-led sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Gwendolen Care Home on our website at www.cqc.org.uk.

Enforcement

We have identified 1 continued breach in relation to the governance at this inspection.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.