CQC report explained · a residential care home
What the CQC found at Gorselands Residential 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
- People had individual risk assessments and staff understood their needs, but some environmental hazards and one person's risks were not fully assessed or dealt with.
- Effective?
- Requires improvement
- Staff were trained and people's healthcare, food and drink needs were generally well managed. Some records about best-interest decisions were unclear, and the environment was not fully suitable for people living with dementia.
- Caring?
- Good
- Staff were kind, patient and respectful. People were involved in decisions, supported to remain independent and treated with dignity.
- Responsive?
- Good
- Care plans reflected people's needs and preferences. People had activities, one-to-one support and help to maintain family relationships.
- Well-led?
- Requires improvement
- New improvement and quality systems were mostly working, but they had not identified all the environmental and record-keeping problems found by inspectors.
What inspectors found, April 2020
Rated Requires Improvement; care was kind and personalised, but safety, consent records and management checks still needed work.
This was an unannounced inspection over 19 and 20 February 2020. Inspectors spoke with people living at the home, relatives and staff. They reviewed care records, medicines records, recruitment information, training records and quality checks.
The home had improved from its previous Inadequate rating and was no longer in Special Measures. Inspectors found enough staff, safe recruitment, good medicines management, kind care, personalised support and varied activities.
However, some environmental risks had not been fully dealt with. Records about consent and some care risks were not always clear or detailed enough. The home's checks had also missed some of these issues.
The overall rating was Requires Improvement. Safe, Effective and Well-led were rated Requires Improvement. Caring and Responsive were rated Good.
Kind and respectful care
People described staff as kind and caring. Inspectors saw staff protecting privacy, offering reassurance and supporting people's independence.
“People told us staff were kind and caring.” from the report
Medicines managed well
People received medicines as prescribed. Storage, stock checks, staff training and checks of staff competence were in place.
“People received their medicines as prescribed and medicines were managed safely.” from the report
Enough familiar staff
Inspectors found enough staff to meet people's needs. The home did not use agency staff and used its own bank staff instead.
“There were enough staff to meet people's needs.” from the report
Personalised activities and support
Care plans recorded people's preferences, and activities included outings, games, exercise, singing and individual time for people who did not want group activities.
“Activities included darts, board games, bingo, exercise and singing.” from the report
Improvement since the last inspection
The provider had introduced new systems and made enough progress for the home to leave Special Measures and no longer be rated Inadequate.
“The rating for this service has now improved to Requires Improvement.” from the report
Environmental hazards
seriousSome furniture was not firmly fixed, a radiator cover was loose and wheelchair parts could cause trips. The stair gate also had not been fully considered for people living with dementia.
“Several large items of furniture were not firmly secured to walls to ensure people did not pull them over and harm themselves.” from the report
Some risks not fully assessed
seriousOne person's frequent movement around the home and entering another person's bedroom had not been fully assessed, including known risks.
“All the risks associated with this, included some which were known risks, had not been fully explored.” from the report
Unclear consent records
needs fixingSome best-interest records did not clearly show how other people's views had been gathered. The provider said these records were reviewed after the inspection.
“However, the records were not always clear about how other people's views had been collected.” from the report
Checks missed some problems
needs fixingThe home's quality systems had not identified some environmental issues and omissions in care records. This meant the improvement plan did not include all the problems inspectors found.
“Some issues found at this inspection had not been identified by the provider's governance systems” from the report
Cold areas
minorSome areas, particularly the dining room, were not warm enough. The provider was addressing boiler problems and used portable heaters and blankets where needed.
“Some areas of the service were not very warm, especially the dining room which several people told us they did not use.” from the report
- 01What action has been completed to secure furniture, the radiator cover and wheelchair parts, and how are these checks recorded?
- 02How do you assess and manage the risks when a person living with dementia enters another person's bedroom?
- 03How do you make sure best-interest records clearly include the views of relatives and other people involved?
- 04What changes have been made to make the home more suitable for people whose dementia may worsen?
- 05What does the current improvement plan cover, and how are you checking that improvements remain in place?
This was an unannounced planned inspection covering all five CQC key questions and both the premises and care provided. This explanation was written from the published report of 9 April 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.
What inspectors found, August 2019
Inadequate and still in special measures; inspectors found kind care and improvements, but serious safety and management problems remained.
This was an unannounced inspection over 26 and 27 March 2019. Inspectors spoke with people, a relative, staff and healthcare professionals. They observed care and reviewed care plans, medicines records, staff files, rotas, training records and safety documents.
The home had improved its medicines management, staff training, staffing levels and environment. People were generally positive about the food and said staff were kind, patient and caring. The home was clean, and staff knew how to respond to abuse concerns.
However, inspectors found serious risks that were not always assessed or managed. These included choking, pressure care, access to the kitchen, fire safety, diabetes care and unclear records about people's changing needs. Staff also needed a better understanding of consent law.
The overall rating was Inadequate. Safe and Well-led were Inadequate, while Effective, Caring and Responsive Required Improvement. The home remained in special measures because people were still at risk from unsafe practice and weak oversight.
Medicines
Medicines, including controlled drugs, were well managed. Records and stock checks were accurate, and staff understood time-sensitive medicines.
“Medicines, including controlled drugs, were well managed and staff were knowledgeable about the medicines they were administering.” from the report
Kind staff
Inspectors saw staff treating people with patience, kindness and respect. People said staff supported their independence and personal care discreetly.
“Staff were kind and showed compassion towards people.” from the report
Staffing and training
There were enough staff to meet people's needs, and staff responded promptly to call bells. Training, supervision and appraisals had improved since the previous inspection.
“Training had improved since our last inspection and staff were very positive about this aspect of their work.” from the report
Clean environment
The home was clean and staff understood infection control. The environment had also been refurbished and was described as warm and comfortable.
“The service was clean and staff regularly carried out scheduled cleaning tasks and were knowledgeable about how to prevent and control infection.” from the report
Unmanaged safety risks
seriousInspectors found several risks that were not properly assessed or controlled. These included unsafe bedrails, access to an open kitchen, poor pressure care and a fire door problem.
“People's safety was compromised because some risks were not well managed and some had not been assessed.” from the report
Unclear diabetes and care records
seriousRecords gave conflicting instructions about blood sugar checks and did not clearly explain safe blood sugar ranges or what staff should do. Changes in people's needs were not always added to care plans.
“Records were unclear and did not contain sufficient guidance for staff.” from the report
Limited activities
minorPeople experienced long periods without meaningful activity. People cared for in bed received very little stimulation outside mealtimes.
“People who were cared for in bed received very little meaningful stimulation outside of mealtimes.” from the report
Weak oversight
seriousThe provider's audits and monitoring systems did not identify all the problems found by inspectors. Similar safety and governance concerns had also appeared at earlier inspections.
“There were widespread and significant shortfalls in service leadership.” from the report
- 01What has been done to prevent people accessing the kitchen when staff are not present?
- 02How are pressure care and repositioning now monitored, especially for people who already have pressure sores?
- 03How are diabetes care plans kept up to date, and how do staff know when to check blood sugar and what action to take?
- 04How do you assess a person's capacity for each care decision, and how do you record best-interest decisions?
- 05What meaningful activities are now available for people who spend much of their time in bed?
This was an unannounced scheduled inspection that assessed the home, the care provided and all five key questions. This explanation was written from the published report of 16 August 2019 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 Gorselands Residential Home
5 rated inspections over 4 years: the service has held its Requires improvement rating throughout.
- April 2020Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2019Inadequatestayed InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- September 2018Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- June 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- August 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- May 2013
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 25 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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Most charge £990 to £1,120 a week. 9 can care for a couple. 14 years' experience on average.
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