Gillingham Road

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

At our last inspection we rated this key question requires improvement. At this assessment the rating has changed to Inadequate. This meant people were not safe and were at risk of avoidable harm. The service was in breach of legal regulations in relation to people’s safe care and treatment, people being protected from the risk abuse and neglect, staff training and supervisions and deployment and the recruitment processes for staff. The principles of RSRCRC were not met as the model of care provided did not allow people to live empowered lives with maximum choice. People’s medicines were not always being managed in a safe way. People were not protected from the risk of abuse. Incidents were not being reported or investigated to reduce risk of reoccurrence.

This service scored 31 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There was no analysis of people’s behaviours of distress to look for trends and themes to reduce further risks. Incidents were not always recorded and where they were, there was not sufficient detail in order to determine how the incident occurred or why. Other incidents were also not analysed to look for trends and themes. This meant there was a delay in putting in place strategies or preventative measures to reduce further risks. There was no evidence of debriefs with staff and incident reports lacked detail on what preceded the incident that led to people’s distressed behaviours.

The provider/registered manager failed to always ensure assessments of people needs before they took on the package of care were detailed. We saw they lacked information about people wants and wishes. Often, they were a cut and paste of the funding authority’s assessment of the person’s needs or the care plan from the previous home. One person told us their relative was not involved in the assessment despite the person wanting them to be. The relative also confirmed they were not asked to be included in this discussions and would have like to have been. They said, “They didn’t involve us at all.”

Leaders failed to ensure people were protected from the risk of abuse and neglect. There was a mixed response from people and their advocates about whether they felt safe. We saw from care notes 1 person had stated they wanted to harm themself. This had not been raised by staff or investigated by the Provider/registered manager. We saw from care notes a person had alleged that staff had been physically aggressive with them. Again, this had not been reported as an incident and was not investigated by the Provider/registered manager. The local authority safeguarding team told us they should have been made aware. Staff told us they would report any safeguarding concerns however they were not always aware of who the safeguarding authority was and just stated they would call their manager, the person’s GP or the Police. However, we found they were not always doing this when issue arose.

The risks associated with people’s care were not managed in a safe way placing people at risk of harm. Where risk assessments were in place, there was a lack of detailed guidance for staff. For example, the risk of pressure sores, oral hygiene, moving and handling, dehydration and malnutrition. Where people had other health concerns, there was a lack of risk assessment in place. For example, where people had catheters, there was no risk assessment in place with guidance for staff on signs to look out for should the catheter block or the person had an infection. Where people required to have their fluid monitored, there was target amounts set so staff knew when to alert the Provider/registered manager. The Behaviour Support plans in place for people did not have sufficient guidance for staff on how to support people when they had incidents of distress or lapses in their mental health. There was a lack of information on what may trigger people or how staff needed to respond when the person was directing their anxiety towards people, staff and others. This placed the person, staff and others at risk of harm.

The provider had failed to ensure the environment and equipment had been set up to ensure people’s and staff safety. One person told us they were concerned about the flooring in their home. They said, “The floor is not great, there is metal by the door [on the floor].” We saw from 1 person’s home there a checklist for staff to test the smoke detector alarms and the fire extinguishers. However, when we asked the member of staff present how they checked this they told us they were not sure. They said, “[Person] has only just moved in, so I am not sure.” However, the person had lived there for several weeks. The provider/registered manager had not undertaken any environmental risk assessments for people to ensure people’s safety.

The provider failed to ensure there were sufficient numbers of qualified staff to ensure people’s safety. Whist people told us staff always turned up to support them, we saw from rotas that staff were often working 2 back-to-back 12-hour shifts and at times more 4 back-to-back shifts. In addition, the provider/registered manager and staff told us that there were no systems in place for staff to have formal breaks during their shifts. This and back-to-back shifts risked staff being fatigued and having no time to decompress. This was particularly concerning given there were no formal breaks and working in, at times, a high-pressure environment given what we were told about people’s high levels of anxiety. We asked the provider/registered manager to address this. We saw from the training matrix provided, out of 12 staff, 9 had either not completed all of their training or had only completed their training in January 2025 after we had requested the training matrix. This placed people at risk as leaders could not be assured staff were providing care in a safe way. We saw one to one supervisions were taking place with staff however there was very little information on the discussions that took place. A supervision should be a discussion about staff professional and personal objectives, so that they can promote the best outcomes for the people they supported. There was no evidence this was happening. The provider did not operate effective and safe recruitment practices when employing new staff. Of the 7 staff files we looked at, 5 did not have a full employment history and 5 staff files had references that either did not match the details of the previous employer of the member of staff, some references were pre-written and not dated and some were recorded as phone references. There was no record of why verbal references were sought instead of written. This meant the provider could not assured of the staff suitability to work at the service.

People were protected from the risk of infection. Staff received infection control training and staff we spoke with had a good understanding of how to prevent infections. The settings we visited were clean and tidy. One member of staff said, “When [person] wants space, we fill the time in between with cleaning and tidying the house.” The provider/registered manager told us staff were able to access Personal Protective Equipment (PPE) in the office or in people’s homes. They said, “We get them [PPE] here in the office and we send some to each homes. When it’s running out, we will deliver more.”

Whilst most people were not supported by staff with their prescribed medicines, we found the management of medicines was not safe. One person told us staff supported them with their medicine and said, “They pass the meds to me.” However, we found there was no Medicine Administration Record (MAR) for the person. The provider/registered manager told us the person was independent with medicines, but they also confirmed that staff stored their medicines in a locked cabinet that only staff could access. When we asked for a MAR to be implemented for the person, this lacked any detail on why the person needed each medicine or if the person was supported with medicines. Staff were not undertaking any counts of the medicines despite there being an incident prior with the person incorrectly taking a medicine intended for the following day. The provider/registered manager confirmed staff had not been competency assessed to ensure they administered in a safe way. This left people at risk of not receiving their correct prescribed medicines and at significant risk of harm to their health.