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Gower Gardens Requires improvement


Inspection carried out on 18 February 2020

During a routine inspection

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 carried out on 26 November 2018

During a routine inspection

This unannounced comprehensive inspection took place on the 26 and 27 November 2018. It was completed on 28 November 2018 following feedback to the management team.

Gower Gardens 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.

Gower Gardens can accommodate up to 66 people. At the time of our inspection 56 people were using the service. Gower Gardens accommodates people across three floors, each of which has individual adapted facilities. The needs of people vary from people living with dementia, mental health or sensory impairment.

At our last inspection in June 2017 we rated the service 'Requires Improvement'. We judged the provider to be in breach of a regulation which required them to notify us of significant events. We also found improvements were needed in how the provider managed risks to people’s care, medicine management and inconsistency in the caring approach of staff. Following the inspection, we asked the provider to complete an action plan to show us what they would do and when by to improve the key questions of safe, caring and well-led to at least ‘Good’. The provider sent us their action plan and we reviewed this as part of this inspection .

This inspection took place to follow up on our previous findings. We checked that the provider was taking action to improve the quality of care and reduce risks to people. During this inspection we found improvements had been made and the provider was no longer in breach of regulations. Systems were in place and followed to ensure they informed us of accidents and incidents that are notifiable. We found the management of risks to people’s safety, and people’s medicines were more robust. The caring approach of staff had improved. The provider had addressed the shortfalls following our previous inspection.

There was an interim management team in place. The provider had recruited a new manager who was not yet in post and not therefore registered with us. 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 a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the service is run. The interim management team had been in post since March 2018 following the previous manager leaving the service.

People felt safe and staff knew how to recognise and report abuse. Risks to people’s safety were identified, monitored and managed. Staffing levels were kept under review to ensure there were sufficient staff to respond to people's needs. Recruitment checks had been carried out to ensure staff were suitable to work with vulnerable people. People received their medicines safely. People were protected from the risk of infection and the home environment was clean.

People were involved in identifying their needs which were met by staff who had training and regular support to develop the skills to meet people’s needs. Staff understood how to support people with eating and drinking and any risks associated with this. People had support to maintain their health and to access healthcare services. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

People were supported by staff who were caring and attentive and who respected their diversity. Staff had a good understanding of promoting and respecting people's privacy, dignity and independence. People were encouraged to express their views and make choices about their daily living. People's contact with relatives and friends was promoted and enhanced by the facilities available to them.


Inspection carried out on 21 June 2017

During a routine inspection

Gower Gardens is registered to provide accommodation and personal care for up to 66 people, who are mainly older people with dementia. At the time of our inspection 46 people were using the service. Our inspection was unannounced and took place on 21 and 22 June 2017. We received concerns that people were not being safely supported in relation to their risk of falls and equipment used for moving and handling people was being incorrectly used. This prompted us to undertake this inspection earlier than was planned and included an evening visit. This was the first inspection since the service was registered in October 2016.

The manager was acting in an interim role and was not registered with us as is required by law. 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 a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the service is run. The acting manager told us they had been in place for two months and our records showed that the previous manager had cancelled their registration in November 2016.

The service was not always effective in how it minimised the impact on people from falling and risk assessments were not always updated as required. Administration and recording of medicines given was not always carried out safely. Staff understood the procedures they should follow if they witnessed or suspected that a person was being abused or harmed. Safe recruitment practices were in place and were followed.

There were concerns that night staff did not know how to support people effectively. Staff received an induction prior to them working for the service and they felt prepared to do their job. Staff could access on-going training to assist them in their role. Staff could access supervision and felt able to ask for assistance from the acting manager and senior staff, if they should need it. Staff knew how to support people in line with the Mental Capacity Act and gained their consent before assisting or supporting them. Staff assisted people to access food and drink and encouraged people to eat healthily. Staff supported people’s healthcare needs.

There were differences between day and night staff as to the level of person centred care provided to people. People were involved in making their own decisions about their care and their own specific needs. People felt listened to, had the information they needed and were consulted about their care. Staff provided care with dignity and respect to people. People were encouraged to retain an appropriate level of independence with staff there ready to support them if they needed help.

People’s preferences for how they wished to receive support were known and considered by the care staff. People were able to participate in activities should they wish to do so. People knew how to raise complaints or concerns and a procedure was in place for staff to follow.

We did not always receive notifications as required. Audits were carried out, but they did not always give enough information to enable people to receive appropriate support. People felt that there was inconsistency in management within the home. People felt settled and liked the environment.