CQC report explained · a nursing home
What the CQC found at Gibraltar Road Nursing Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Some care plans and risk assessments were not up to date, and one person's required blood pressure checks were not recorded. Medicines, staffing, safeguarding arrangements and most infection controls were otherwise found to be in place.
- Effective?
- Good
- This key question was not inspected during this focused inspection. Its previous rating was used when calculating the overall rating.
- Caring?
- Good
- This key question was not inspected during this focused inspection. Its previous rating was used when calculating the overall rating.
- Responsive?
- Good
- This key question was not inspected during this focused inspection. Its previous rating was used when calculating the overall rating.
- Well-led?
- Requires improvement
- Quality monitoring systems, audits and records were not consistently completed or effective. The provider had not identified all the concerns found by inspectors and had not always sent required notifications to CQC.
What inspectors found, March 2023
Rated Requires Improvement; inspectors found kind, person-centred care but gaps in care records and quality checks created safety risks.
This was an unannounced focused inspection on 10 January 2023. One inspector and an Expert by Experience spoke with staff and relatives, observed care, and checked care, medicines, staffing and management records.
The home supported eight people, although it could support up to 10. People were treated with privacy and dignity, staff responded promptly, and medicines, staffing checks and infection control were mostly managed safely.
Inspectors found that some care plans and risk assessments were out of date or incomplete. Quality checks and audits were not used consistently, and some required notifications were not sent to CQC. These weaknesses meant people could be at increased risk of not receiving safe care and treatment.
The overall rating changed from Good at the previous inspection to Requires Improvement. The inspection looked only at Safe and Well-led. The other key question ratings were carried forward from the previous inspection.
Choice and dignity
People were supported to make choices and staff used the least restrictive approach. Inspectors saw person-centred and respectful interactions.
“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” from the report
Staffing and relationships
Recent recruitment and less use of agency staff had helped create a more consistent team. Staff responded promptly and supported people in a person-centred way.
“recent recruitment meant there had been less use of agency staff” from the report
Medicines and infection control
Medicines were stored securely, audits were completed monthly, and most infection prevention arrangements gave inspectors assurance.
“Medicines audits were completed monthly and any issues were dealt with in a timely manner.” from the report
Communication with relatives
Relatives said they were kept informed and could contact the manager. They also said visiting arrangements worked well.
“Relatives confirmed they were able to see their relative when they wanted to” from the report
Out-of-date care information
seriousSome care plans and risk assessments were not current. One person's required blood pressure monitoring had no records, creating a risk that care needs would be missed.
“This meant we were not assured that risks to people were always being managed safely.” from the report
Weak quality monitoring
seriousThe home's audits, checks and management reviews were not consistently completed or effective. The provider's review did not identify all the problems inspectors found.
“Systems and processes to monitor the service were not robust and we were not assured the provider's oversight and governance of the service was effective” from the report
Required notifications
needs fixingThe provider notified the local safeguarding team about allegations of abuse but did not consistently notify CQC. The manager had a plan to address this.
“However, they had failed to consistently notify CQC about some of these allegations.” from the report
Incomplete medicines record
needs fixingFor one person, body map records for applying eye gel were missing. A staff member corrected this during the inspection.
“for one person, body map records related to the administration of eye gel were absent.” from the report
- 01How have you ensured every person's care plan and risk assessment is accurate and reviewed regularly?
- 02How do you now record health checks, including blood pressure monitoring where required?
- 03What quality audits and management checks are being completed, and can we see evidence of recent actions taken?
- 04How do you ensure all incidents and safeguarding allegations that must be reported are notified to CQC?
- 05What progress has been made on the improvement plan and the action plan requested by CQC?
This was an unannounced focused inspection of Safe and Well-led, with infection prevention and control also considered; the other key question ratings were carried forward from the previous inspection. This explanation was written from the published report of 29 March 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, December 2020
Inspected but not rated; inspectors found good infection control arrangements during the coronavirus-focused visit.
Inspectors visited the home on 2 December 2020. The visit was announced and focused only on infection prevention and control measures.
They found the premises clean, with hand sanitisers and protective equipment stations throughout the building. Staff were seen wearing suitable protective equipment, and the home had clear safety instructions.
Inspectors were assured about visitor safety, social distancing, testing, protective equipment, hygiene, outbreak management and the infection control policy. The home was inspected but not rated, so this report does not give an overall quality rating.
Clean premises and equipment
The home was clean and had hand sanitisers and protective equipment stations throughout the building.
“The premises looked clean. Hand sanitisers and PPE stations were situated throughout the building.” from the report
Staff protection
Staff were observed wearing suitable protective equipment, with clear signs explaining the safety procedures.
“Staff were observed wearing appropriate PPE. There was prominent signage and instructions to explain what staff should do to ensure safety.” from the report
Keeping in touch
The home used video calls and other ways to help residents stay in contact with relatives and friends.
“Alternative forms of maintaining social contact were used for friends and relatives; for example: keeping in touch using video calls.” from the report
Laundry arrangements
The home had a process to prevent residents' clothes from being mixed and washed together.
“The service had laundry processes in place so clothes were not mixed and washed together.” from the report
Inspectors raised no specific concerns in this report.
- 01How are visitors currently protected from catching or spreading infections?
- 02How do you make sure residents and staff can access testing when needed?
- 03How do you manage an infection outbreak if one occurs?
- 04How do you make sure protective equipment is used safely by all staff?
- 05How are relatives helped to keep in touch with residents?
This was a targeted inspection of infection prevention and control practices only; the service was inspected but not rated and the report does not assess the other areas of care. This explanation was written from the published report of 17 December 2020 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Gibraltar Road Nursing Home
4 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- March 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2020Inspected but not ratedSafe: Inspected but not rated
- September 2019Goodup from Requires improvementSafe: GoodWell-led: Good
- August 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- March 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2014
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 13 January 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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