CQC report explained · a residential care home
What the CQC found at Gwendolen Road Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, February 2023
Rated Requires Improvement and no longer in special measures; inspectors found kind care and clear improvements, but governance and some safety checks still needed work.
This was an unannounced follow-up inspection on 10 and 11 January 2023. Inspectors spoke with people, relatives, staff, managers and a healthcare professional. They observed care and reviewed care plans, staff files, medicines records, audits and other records.
The home had improved since its previous inadequate rating. Inspectors found kind and respectful care, better care plans, safer staffing, improved cleanliness and better support for people's health, communication and community activities. The overall rating improved to Requires Improvement, and the home was no longer in special measures.
Some important weaknesses remained. Medicines stock and opened-date records were not always complete. Checks and audits had not found these problems, and senior oversight was not strong enough. The provider remained in breach of Regulation 17 on good governance and was asked to provide an action plan.
Kind and respectful care
Inspectors saw staff treating people with kindness, compassion and respect. People were offered choices and encouraged to remain independent.
“People received care and support that was kind, caring and compassionate.” from the report
Cleaner environment
The home had improved its cleanliness and infection control. Inspectors found the environment, furnishings and equipment clean and hygienic.
“The environment, including furnishings and equipment were found to be clean and hygienic.” from the report
Better personalised information
Most care plans had been reviewed and staff had detailed, up-to-date guidance about people's needs, routines and preferences.
“Guidance for staff about how to meet people's individual needs was detailed and up to date.” from the report
Communication support
Staff understood people's communication needs and supported some people in their first language, which was not English.
“People's communication needs, and preferences were known and understood.” from the report
Safer staffing
Staff were recruited with the required checks, received induction and shadowed experienced staff before working independently.
“Staff were recruited safely and received an induction before working with people independently.” from the report
Medicines records
needs fixingMedicines were observed being given safely, but stock checks and recording the date medicines were opened were not consistent. The management team took immediate action after this was raised.
“The monitoring of medicines stock and the dating of medicines when opened, were not consistently being recorded.” from the report
Assessing new referrals
needs fixingThe home had accepted emergency referrals without enough evidence that compatibility, staffing skills and resources had been considered. Inspectors said this could affect whether people's individual needs were met.
“The process of assessing new referrals to the service was not sufficiently robust.” from the report
DoLS care plans
needs fixingNot everyone had a care plan explaining the reason for their authorisation and its conditions. Staff understood the arrangements, and managers started developing the missing plans during the inspection.
“We identified that all people did not have a DoLS care plan to inform staff of the reason for a DoLs authorisation and details of any conditions.” from the report
- 01What has changed in the medicines audit system since the inspection, and how do you now check stock levels and opened dates?
- 02How will senior managers record their audits and make sure problems are acted on promptly?
- 03How do you assess whether a new or emergency referral is compatible with people already living here?
- 04Which residents still need DoLS care plans, and when will these be completed?
- 05How will you help each person identify and work towards their goals and aspirations?
This was an unannounced follow-up inspection after the previous inadequate rating, covering all five key questions and checking action required from the earlier inspection. This explanation was written from the published report of 14 February 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 2022
Overall rating Inadequate and in special measures; inspectors found serious failures in safety, staffing, consent, personalised care and management.
The inspection was unannounced and involved visits on 8, 9, 10 and 30 August 2022. Inspectors spoke with people living at the home, relatives and staff. They reviewed care plans, medicines records, recruitment files and other records, and observed care.
Inspectors found people were at risk of harm. Safeguarding concerns had not always been reported, some people were deprived of their liberty without lawful authority, medicines were not managed safely and staffing levels did not always meet people's needs. The home was also unclean and in poor repair.
Care was not always based on people's needs, choices or communication. Staff training was not sufficient, activities and community access were limited, some people's privacy and dignity were not respected, and complaints were not always resolved. Management checks did not identify or act on problems.
The overall rating fell from Good at the previous inspection to Inadequate. Caring was rated Requires Improvement. The home was placed in special measures, meaning the CQC will keep it under review and may re-inspect within six months.
Recruitment checks
The four recruitment files inspected contained the information required by law, and the provider was following its recruitment process.
“The four staff files we reviewed contained all of the information required by law.” from the report
Choice at mealtimes
Inspectors saw people being offered choices at lunch and snacks and drinks during the day. People said they enjoyed the food.
“The food is nice, I get a choice of what to eat.” from the report
Contact with loved ones
People were supported to keep in touch with family members by telephone or iPad. Friends within the home were also supported to spend time together.
“People were supported to keep in touch with loved ones.” from the report
People could share views
The home held meetings for people living there. Some people were supported by staff who spoke their native language so they could raise issues.
“People who could not easily express their views were supported by a staff member who spoke their native language.” from the report
Protection from harm
seriousSafeguarding issues had not always been identified or reported. Inspectors made safeguarding referrals for seven people, and some people were deprived of their liberty without lawful authority.
“People were not adequately protected from the risk of harm.” from the report
Medicines
seriousControlled drugs were not always counted correctly. Information about medicines given when needed was unclear, and some medicines were crushed without fresh medical authorisation.
“Medicines were not always managed safely.” from the report
Staffing and training
seriousThere were not enough staff for some people's assessed support levels. Training records were not up to date, and staff could not show competence in areas including safeguarding and fire safety.
“There were not enough staff deployed to meet people's individual needs and keep them safe from harm.” from the report
Poor environment and cleanliness
seriousThe home and bedrooms were dirty and in disrepair. Inspectors found mould, dirt, damaged furnishings, unsafe garden areas, a bedbug infestation and accessible clinical waste.
“Cleaning procedures within the home did not ensure a clean and hygienic environment for people.” from the report
Limited activities and choice
needs fixingPeople were not consistently supported with hobbies, meaningful activities or community access. Care plans did not clearly show who people chose to support them or how they wanted to be supported.
“The service failed to support people to maintain their hobbies and interests, and provide meaningful activities, or enrichment for people to participate in.” from the report
Weak management checks
seriousAudits were rare or ineffective and did not identify problems found by inspectors. Concerns were sometimes left unresolved, and records did not show that lessons had been learned.
“The provider failed to establish robust governance systems to oversee the quality and safety of the service.” from the report
- 01What action has been taken to protect people from safeguarding risks and to make sure all liberty restrictions have lawful authorisation?
- 02How are controlled drugs now counted, and how are staff checked when giving medicines, including medicines given covertly or crushed?
- 03How do current staffing levels match each person's one-to-one or two-to-one support needs?
- 04What has been repaired or replaced in the building, bedrooms and garden, and how is cleanliness now checked?
- 05What activities, communication support and community access are now available for each person?
The inspection began as a focused review of Safe and Well-led following concerns, then became a comprehensive inspection covering all five key questions; the previous ratings were Good in 2019. This explanation was written from the published report of 12 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.
Every inspection of Gwendolen Road Care Home
4 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- February 2023Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- December 2022Inadequatedown from GoodSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: InadequateWell-led: Inadequate
- October 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2016
Registered with the Care Quality Commission on 13 May 2016.
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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