CQC report explained · a nursing home
What the CQC found at Gillibrand Hall Nursing Care 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
- Medicines were not always recorded, stored or administered safely. Fire safety actions were still being completed, and some risk assessments were not reviewed as required.
- Effective?
- Good
- This key question was not inspected during this focused inspection. Its previous rating was carried forward when calculating the overall rating.
- Caring?
- Good
- People were treated with kindness, dignity and respect. They and their relatives spoke highly about the staff and were involved in decisions about care.
- Responsive?
- Good
- This key question was not inspected during this focused inspection. Its previous rating was carried forward when calculating the overall rating.
- Well-led?
- Requires improvement
- The manager and staff understood their roles, but some regulatory requirements and quality checks were not applied consistently. Medicine audits had not led to lasting improvements.
What inspectors found, December 2022
Requires Improvement; inspectors found kind care, but medicines safety and management systems needed improvement.
This was an unannounced focused inspection on 26 and 31 October 2022. One inspector spoke with five residents, five relatives and 15 staff. They checked care plans, risk assessments, medicines records, recruitment records, policies and audits.
The home was caring, clean and welcoming. People and relatives said they felt safe and well cared for. Staff treated people with kindness and respect. There were regular activities, social opportunities and transport for outings.
There were important safety problems with medicines records and storage. Fire safety work was still ongoing. Some agency staff did not know people as well as permanent staff. The home had not consistently followed some regulatory and governance requirements. The overall rating changed from Good to Requires Improvement.
Kind and respectful care
People and relatives spoke highly about the home and staff. Inspectors saw people treated respectfully and in a caring way.
“We saw that staff treated people respectfully and in a caring manner during the inspection.” from the report
People felt safe
People and relatives said they felt safe and well cared for. Safeguarding training was up to date and concerns were acted on.
“People and their relatives told us they felt safe and well cared for.” from the report
Activities and outings
People had regular opportunities for activities, social contact and outings. The home had two full-time activities co-ordinators and its own transport.
“People enjoyed living at the home and there was a good amount of activities and opportunities to go out socially.” from the report
Permanent staff knew people well
Permanent staff were described as knowledgeable about people's needs. Recruitment checks were completed for staff.
“Permanent staff know (my relative) inside out, they know how best to care for her and know what to do in different situations.” from the report
Medicines were not managed safely
seriousSome medicines were not signed for, opened dates were missing and storage temperatures were not always recorded. Guidance for medicines given when needed was also incomplete, and an overfull sharps bin was seen.
“Although we found no evidence of harm, systems for managing medicines were not always safe and effective.” from the report
Fire safety work was incomplete
needs fixingThe fire service had issued an enforcement notice. Several actions had been completed, but further work was still needed and an extension ran until 13 January 2023.
“On 14 April 2022 the fire service issued an enforcement notice meaning actions were required for the home to comply with fire safety regulations.” from the report
Agency staff had less knowledge
needs fixingThere was a high reliance on agency staff, and some did not have the required knowledge, experience or skills. This placed extra pressure on permanent staff.
“There was a high reliance on agency staff.” from the report
Governance checks were not consistent
needs fixingSome safeguarding notifications were not made and there was no overall log of safeguarding alerts and investigations. Medicine audits had not embedded the needed improvements.
“There was no overall log of safeguarding alerts and investigations which meant recommendations made by the local authority could be missed.” from the report
- 01What changes have you made to ensure every medicine is signed for, stored correctly and recorded with the right instructions?
- 02How do you now check medicine fridge and storage-room temperatures, opening dates and thickener amounts?
- 03What progress has been made on the fire service enforcement notice, and what work remained outstanding?
- 04How are agency staff introduced to each person's needs, and how do you ensure they have the right skills and supervision?
- 05How do you record safeguarding alerts and make sure all required notifications are sent?
This was a focused inspection of Safe, Caring and Well-led; Effective and Responsive were not inspected and their previous ratings were used when calculating the overall rating. This explanation was written from the published report of 3 December 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, March 2022
Inspected but not rated; inspectors found generally safe infection-control arrangements, but the policy needed updating.
This was an announced, targeted inspection on 1 February 2022. Inspectors looked at infection prevention and control, including visiting arrangements, testing, protective equipment, cleanliness and staffing pressures linked to COVID-19.
Inspectors were assured about most infection-control arrangements. The home supported visits, testing and vaccination requirements, and had suitable supplies of protective equipment. The home was clean and well maintained.
There were some shortfalls. Inspectors were only somewhat assured about the layout and hygiene practices, and were not assured that the infection-control policy was up to date. The service was signposted to the local authority for additional support.
The home was inspected but not rated. This was not a full assessment of the home's overall quality, and the report does not give ratings for caring, effective, responsive or well-led care.
Testing and protective equipment
People and staff were tested regularly. Staff had training in infection prevention and in putting on and taking off protective equipment, and the home had adequate supplies.
“The home had adequate supplies of appropriate PPE.” from the report
Clean premises
Inspectors found the home clean and well maintained. Cleaning schedules and audits were used to help maintain cleanliness.
“The home was clean and well maintained. Cleaning schedules and audits were in place to help maintain cleanliness and minimise the spread of infection.” from the report
External health support
The manager kept links with external health professionals, and virtual consultations were used when needed.
“The registered manager maintained links with external health professionals to enable people to receive the care and intervention they needed.” from the report
Policy not up to date
needs fixingInspectors were not assured that the infection prevention and control policy reflected current guidance and best practice. The service was referred to the local authority for additional support.
“We were not assured that the provider's infection prevention and control policy was up to date.” from the report
Limited visual reminders
minorThere were no posters around the home reminding staff and visitors about infection prevention and the use of protective equipment.
“However, we noted there were no posters around the home to act as a visual reminder and prompt for staff and visitors on infection prevention and use of personal protective equipment (PPE).” from the report
Layout and hygiene practices
needs fixingInspectors were only somewhat assured that the layout and hygiene practices of the premises promoted safety.
“We were somewhat assured that the provider was promoting safety through the layout and hygiene practices of the premises.” from the report
- 01Has the infection prevention and control policy now been reviewed and updated to reflect current guidance and best practice?
- 02What changes have been made to the layout and hygiene practices since the inspection?
- 03Have posters or other visual reminders about infection prevention and protective equipment been put up?
- 04How are COVID-19-related staffing pressures being managed, and have they affected people's care?
- 05How are family visits, visitor testing and vaccination requirements being managed now?
This was a targeted inspection of infection prevention and control and COVID-19-related staffing pressures; it was not a full inspection and the service was inspected but not rated. This explanation was written from the published report of 3 March 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 Gillibrand Hall Nursing Care Home
4 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- December 2022Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Gillibrand Hall Nursing Care Home →
- March 2022Inspected but not ratedSafe: Inspected but not rated
Read what inspectors found at Gillibrand Hall Nursing Care Home →
- January 2021Goodstayed GoodSafe: GoodWell-led: Good
- March 2019Goodstayed GoodSafe: Requires improvementCaring: GoodWell-led: Good
- September 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2014
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- August 2011
Report published without a new overall rating.
- April 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 15 December 2010.
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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