CQC report explained · a nursing home
What the CQC found at Gibson's Lodge Limited
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, July 2022
Gibson's Lodge Limited is Rated Good; inspectors found safe, kind and personalised care, with clear improvements since the previous inspection.
Inspectors made an unannounced, comprehensive visit on 14 June 2022. They spoke with people living in the home, staff and managers. They observed care and checked care records, staff files, medicines records and management checks.
All five areas were rated Good. Inspectors found that risks were better assessed, medicines were managed safely, staffing and recruitment checks had improved, and infection control arrangements were suitable.
People said staff were kind, knew them well and responded to their needs. Care plans were detailed and personalised. The home had followed its action plan after the previous inspection, when its overall rating was Requires Improvement and there were several legal breaches.
Safer care systems
Risk assessments and guidance were available to staff. Medicines, bed rail risks, recruitment checks and premises safety were all found to be better managed.
“Risks of avoidable harm were reduced because the provider had improved their assessing and risk management processes.” from the report
Kind and respectful staff
People described staff positively, and inspectors saw warm interactions. Staff treated people with dignity and understood their personal preferences.
“Staff were kind and we observed many caring and warm interactions.” from the report
Personalised care
Care plans included people's health needs, backgrounds, personalities and preferences. People and relatives were involved in planning and reviewing care.
“Care plans detailed people's health needs, backgrounds, personalities, those who were important to them and how they preferred to receive their care.” from the report
Improved leadership
The home had more stable management, stronger checks and better records than at the previous inspection. Staff said morale was high and they enjoyed their work.
“The registered manager had been in post for approximately a year and had brought stability to the service.” from the report
Short staff summaries
minorThe basic summaries used to brief new or agency staff did not include as much detail as they could have. This could make the induction of unfamiliar staff less helpful.
“However, as some care plans were lengthy, these 'at a glance' summaries could be more detailed to assist in the staff induction period.” from the report
- 01How do you make sure new and agency staff understand the detailed care plans, as inspectors said the short summaries could be more detailed?
- 02How often are people's risk assessments and care plans reviewed, especially for bed rails, pressure ulcers, diabetes and behaviours that may cause distress?
- 03How do you check that medicines, including any hidden in food, remain suitable and are given as prescribed?
- 04How do people and their relatives take part in care plan reviews and decisions about care?
- 05What checks show that the improvements made after the previous inspection have continued since June 2022?
This was an unannounced comprehensive inspection covering all five key questions and checking improvements required after breaches at the previous inspection. This explanation was written from the published report of 15 July 2022 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, September 2021
Overall rated Requires Improvement; inspectors found kind care, but significant safety, care-record and leadership shortfalls, with Well-led rated Inadequate.
This was a comprehensive inspection on 28 May 2021. Inspectors spoke with people and staff, observed care, reviewed care records, recruitment files, medicines records and management information. They also considered infection prevention and control.
The home was not always safe or effective. Inspectors found risks around bed entrapment, medicines, recruitment checks, care planning and consent under the Mental Capacity Act. Records did not always show the care given, and audits had failed to identify or resolve these problems.
Staff were kind, respectful and knew people well. People had choices about food and care, and healthcare needs were generally supported. However, the home had experienced management instability, staff felt unsupported, and leadership systems were rated Inadequate.
Kind and respectful staff
People said they liked the staff. Inspectors saw staff provide care discreetly, explain what they were doing and treat people with dignity.
“Staff were respectful towards people and treated people in a dignified manner.” from the report
People’s choices
People were involved in choices about their care, food and drink. Staff understood individual preferences and encouraged independence.
“We observed staff encouraging people to make their own choices about their care, such as their food and drink.” from the report
Food and healthcare support
People were offered a choice of hot food and drink in sufficient quantities. Staff supported people with day-to-day health needs and followed advice from healthcare professionals.
“People told us they had enough to eat and drink and they enjoyed the food.” from the report
Infection-control arrangements
Inspectors were assured about visiting arrangements, personal protective equipment, testing and the prevention and management of outbreaks. Some bed bumpers, however, were not hygienic.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Bed and fire safety
seriousSeveral people were at risk of entrapment in their beds because risks had not been properly assessed or controlled. A kitchen fire door was also propped open with cardboard.
“Nine people were at risk of entrapment in their bed rails as the provider had neglected to ensure bumpers reduced this risk.” from the report
Medicines management
seriousSome covert medicines had been crushed without evidence that this was safe. Medicine stocks did not match records, and some medicines were not given as prescribed.
“This meant people had not always received their medicines as prescribed.” from the report
Consent and capacity decisions
seriousThe home had not completed decision-specific mental capacity assessments or followed best-interest processes for some medicines and bed-rail decisions. This concern had been found at the previous inspection too.
“The provider had not followed their action plan to improve in relation to the MCA and covert medicines as we identified the same concern again at this inspection.” from the report
Incomplete care plans and records
needs fixingSome people did not have care plans for needs such as pressure-ulcer prevention, catheter care, diabetes or challenging behaviour. Records also did not show when some people had been repositioned.
“Care plans relating to pressure ulcer prevention, catheter care, diabetes and challenging behaviour were not in place for some people who needed them.” from the report
Weak staff support and oversight
seriousStaff did not always receive regular supervision or appraisal. Management turnover and ineffective audits meant important problems were not identified or put right.
“The provider's systems to ensure the care people received was good enough were inadequate with poor managerial oversight.” from the report
- 01What has been done to remove the bed-entrapment risks and replace the damaged bed bumpers?
- 02How do you now check that every covert medicine is safe to crush and that medicines are given as prescribed?
- 03Can you show how decision-specific capacity assessments and best-interest decisions are recorded for medicines and bed rails?
- 04Which care plans and daily records were missing at the inspection, and how can I check they are now complete and accurate?
- 05How are staff supervision, recruitment checks and management oversight being monitored under the monthly action plan?
This was a comprehensive inspection covering all five key questions, including infection prevention and control, following the previous rating and concerns about behaviour that challenges. This explanation was written from the published report of 21 September 2021 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 Gibson's Lodge Limited
8 rated inspections over 7 years: the service has improved, from Requires improvement to Good.
- July 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2021Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Inadequate
- October 2019Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2019Inadequatedown from GoodSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- March 2017Goodstayed GoodSafe: Good
- June 2016Goodstayed GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2015Goodup from Requires improvementSafe: GoodEffective: GoodWell-led: Good
- April 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- August 2011
Report published without a new overall rating.
- February 2011
Registered with the Care Quality Commission on 14 February 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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