CQC report explained · a residential care home
What the CQC found at Gilburn
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, September 2022
Gilburn was rated Requires Improvement; inspectors found kind care, but serious staffing, training and management checks needed strengthening.
This was the home’s first inspection. It was unannounced and took place on 27 and 28 June and 5 July 2022. Inspectors spoke with people living at the home, staff and other professionals, and checked care, medicines, staffing and management records.
The home was rated Good for Caring. People were treated kindly and with dignity. Staff supported people to make choices, stay independent, take part in activities and access the local community.
The other four areas were rated Requires Improvement. There were not always enough suitably trained staff, some staff worked very long shifts, and care records and checks on incidents were not always reliable. CQC found breaches of the rules on staffing and good governance.
The provider said staffing and training had improved during and after the inspection. CQC asked for an action plan and said it would monitor progress.
Kind and respectful care
People told inspectors they felt safe and supported. Staff were friendly, reassuring and respectful of privacy, dignity and personal choices.
“People were well cared for and they liked the staff at the home.” from the report
Choice and independence
People were supported to make decisions, personalise their apartments, cook, manage activities and access the community.
“Staff supported people to have the maximum possible choice and control over their own lives and to be independent.” from the report
Medicines managed safely
Medicine records were completed accurately. Staff had guidance for medicines given when needed, and medicines training and checks were carried out.
“Medicines were managed safely.” from the report
Personalised environment
Apartments were adapted to individual needs and people were involved in plans to improve shared spaces and activities.
“Each person's apartment was personalised and adapted to meet their individual needs.” from the report
Partnership working
The home worked with mental health, learning disability and social care professionals. Staff made healthcare referrals when needed.
“We saw the service were working in partnership with other agencies.” from the report
Not enough staff
seriousStaffing levels did not always match people's needs. Some people did not receive the required one-to-one or two-to-one support, particularly at night, and some staff worked very long hours.
“There were not always enough staff to provide safe care.” from the report
Training gaps
seriousSome permanent and agency staff had not completed important training about individual risks, restraint and ligature safety. This increased the risk of harm to people and staff.
“Agency staff were not trained to support people safely.” from the report
Care records not always current
needs fixingCare plans and daily notes did not initially show that people were receiving personal care. This meant inspectors could not be sure that all care information was accurate and up to date.
“Staff did not always have the most current information relating to people's needs.” from the report
Weak management checks
seriousAudits did not identify several problems found by inspectors. The service development plan had no clear priorities, deadlines, named responsibilities or progress updates.
“Systems and processes were not always effective in identifying concerns we found during inspection.” from the report
Incident learning
needs fixingDebriefs after incidents did not happen consistently, and incident information was not always analysed for patterns or lessons.
“There was an inconsistent application of debriefs when incidents occurred.” from the report
End of life wishes
needs fixingEnd of life planning had not been considered consistently for everyone. The report says no one at the time had a life-limiting diagnosis or was receiving end of life care.
“End of life care plans were not always in place and there was an inconsistent approach to consideration of end of life care planning.” from the report
- 01How many permanent and agency staff will be on duty for my relative, including overnight?
- 02Have all staff supporting my relative completed training for their specific risks, including restraint and ligature safety?
- 03How do you check that care plans and daily notes contain current information about personal care needs?
- 04What changes have you made to make incident debriefs and learning consistent?
- 05What progress has been made on the action plan required by CQC, and how is this being checked?
This was an unannounced comprehensive inspection of the newly registered home and covered all five CQC key questions, including infection prevention and control. This explanation was written from the published report of 21 September 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.
Every inspection of Gilburn
Each visit the CQC has published, newest first, back to the day the home was registered.
- September 2022Requires improvementcurrent ratingSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2021
Registered with the Care Quality Commission on 8 July 2021.
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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
At least 100 live-in carers within about an hour of Leicestershire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,260 a week. 82 can care for a couple. 12 years' experience on average.
“If you bump into her in the night on her way to the bathroom she will still inquire how you are and if everything is alright.”
“Together Earther and I supported her to die at home with great dignity and compassion and him to continue with life.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.