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Gower Gardens Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 2 April 2020

About the service

Gower Gardens is a residential care home providing personal care to 61 people aged 65 and over at the time of the inspection. The service can support up to 66 people.

The care home accommodates people across three separate floors, each of which has separate facilities. It provides care to older people, some of whom are living with dementia.

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

The service was not always well-led. The registered provider had established some systems and processes that were necessary to operate, monitor and evaluate the operation of the service, however these needed further development to ensure they consistently identified and addressed shortfalls. Some new systems had been introduced, however these needed to be sustained and embedded into practice. People, and staff told us the provider and manager were approachable. The manager, who was not available when we inspected was acting in an interim role and was not registered with us as required by law.

People did not always receive safe care. Although people told us they felt safe, risks to people's safety had not always been assessed and mitigated against. Overall people were supported to receive their medicines as required however, improvement was required in some areas of medicine practice. Staff understood how and when to raise any safeguarding concerns. We received some mixed views from people and relatives regarding staffing arrangements. Safe recruitment practices were in place and were followed. The general day to day practice supported infection control, but improvement was required to ensure appropriate lidded bins were available in bathrooms.

Staff liaised with other health care professionals to meet people’s health needs and support their wellbeing, but improvement was needed to weight monitoring and to ensure people received appropriate dental care. We saw people’s food choices were explored with them and that staff understood people’s specific dietary needs.

We observed kind and friendly interactions between the staff and people. People told us they were treated with kindness and compassion. However, we found concerns that, on occasions, compromised people’s dignity and privacy.

People did not always receive responsive care. Care records were reviewed but people had not had the opportunity to have input into these reviews. People we spoke with knew how to raise a concern or make a complaint. A log was kept of complaints received but this did not always record the outcome of the complaint or any action taken. People had the opportunity to participate in activities of interest to them.

For more details, please see the full report which is on the CQC website at

Rating at last inspection

The last rating for this service was good (published 22 December 2018).

Why we inspected

The inspection was prompted in part due to concerns received from whistle blowers and members of the public about medicines, staffing, moving and handling of people and care provided to people. We decided to inspect and our inspection included examining the concerns shared with us.

We have found evidence that the provider needs to make improvements. Please see the safe, effective, caring, responsive and well led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.


We have identified breaches in relation to Safe care and treatment and Good Governance at this inspection.

Please see the action we have told the provider to take at the end of this report.

Inspection areas


Requires improvement

Updated 2 April 2020

The service was not always safe.

Details are in our safe findings below.


Requires improvement

Updated 2 April 2020

The service was not always effective.

Details are in our effective findings below.


Requires improvement

Updated 2 April 2020

The service was not always caring.

Details are in our caring findings below.


Requires improvement

Updated 2 April 2020

The service was not always responsive.

Details are in our responsive findings below.


Requires improvement

Updated 2 April 2020

The service was not always well-led.

Details are in our well-Led findings below.