Gosberton House Care Home

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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

At the last assessment the provider was in breach of regulations in relation to the management or risk, medicines management, and staff training. At this assessment we found there had been some improvement and the provider was no longer in breach. However, more time was needed to ensure that the improvements became embedded in the care provided.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. However, this had only just been put in place as part of the improvements the interim manager had put in place. It would need to be embedded in daily care to support a learning culture in the home. Previous to the interim manager starting there had been a lack of recording of incidents and accidents in the home. This meant opportunities to learn and improve the quality of care provided had been missed.

Staff were able to tell us about incidents they should report. They were clear on how incidents should be reported and were able to tell us about how they learned to improve safety following incidents. For example, one person now used a senor mat following a fall. This alerted staff so they could provide support when the person wanted to walk around the home.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

Relatives were confident that their loved ones were safe in the home. They were happy to raise any concerns they had with the provider.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

Staff told us they had received training in how to keep people safe from abuse. They were clear how to raise concerns within the home to keep people safe. In addition, they had received training on how concerns could be raised with external agencies if needed.

Care plans did not contain all the information required to keep people safe while providing care. For example, risk assessments were not in place around pressure areas and nutritional needs. We raised this with the interim manager who had also identified this as a concern. They showed us a care plan they had re-written and this contained all the information needed to keep people safe. We requested that they review everyone’s risk assessments in a timely manner. When we went back to the home to feedback the findings from the assessment we saw all the care plans had been re-written to accurately reflect people’s needs.

People received the care which met their needs. Despite their being no written risk assessment’s in place staff did know about people’s needs. In each carer’s office there was a board of people’s needs and how what care was needed to support them safely. For example, where needed people had appropriate equipment in place to prevent pressure areas and where people were at risk of malnutrition their food was fortified with cream and butter to increase calorie intake. Where needed people had been prescribed nutritional supplements from their GP and their nutritional intake was recorded to ensure they were receiving enough calories to maintain a healthy weight .

The provider detected and controlled most potential risks in the care environment. They made sure facilities supported the delivery of safe care .

However, we saw staff had failed to identify a concern for one person who was cared for in bed. This person was tall and had needed their bed extending. They had not been provided with an appropriate mattress to fit the bed. This meant that the person had not been supported effectively and may have impacted on their well-being. We raised this with the provider who took immediate action to order the appropriate equipment. The next day the person’s mattress had been updated, was safe and supported their care needs.

There had been a recent review of fire safety in the home and the provider had updated the fire alarms in response to the recommendations made. Action had also been taken to ensure the fire doors met the required standards.

Other equipment was well maintained and serviced regularly. For example, equipment to support people to move safely such as hoists, had been serviced over the summer.

The provider had a maintenance plan in place to ensure where needed areas of the home were redecorated. They were happy to share this with relatives and residents so they could be held accountable if work was not completed.

The provider made sure there were enough qualified, skilled and experienced staff. However, they did not always make sure staff received effective support, supervision and development. .

Staff were able to tell us about the training they had completed. However, recording of staff training had not been consistently completed. Therefore, it was not always possible to identify if staff had received all the training needed to provide safe care to people. In addition, regular staff meetings had not been taking place to ensure staff remained up to date with changes in the home.

The provider and interim manager followed recruitment processes to ensure staff were safe to work with people living at the home. A Disclosure and Barring Service (DBS) check was completed on staff. Disclosure and Barring Service (DBS) checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff had received training in how to clean the environment effectively and worked in line with the provider’s policies and best practice guidelines. In addition, staff wore protective equipment such as gloves and aprons to minimise the risk of infection spreading around the home. They were clear on when to change protective equipment to keep people safe.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Staff told us they had completed training in supporting people to take their medicines safely. In addition, staff had been observed administering people’s medicines to ensure they had understood the training, supported people safely and worked in line with the provider’s policies.

Records showed people had received their medicines as prescribed. Where people had been prescribed medicines to be taken as required protocols were in place to support staff to assess the person’s needs and administer medicines consistently.

Where people had their medicines administered covertly appropriate mental capacity assessments had been completed and advice sought from their GP and a pharmacist.