10 January 2023
During an inspection looking at part of the service
About the service
Gibraltar Road Nursing Home is a nursing care home providing personal and nursing care to 8 people at the time of the inspection. The service can support up to 10 people.
People’s experience of using this service and what we found
Right Support: People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. The provider acknowledged they were undertaking a thorough review of the service. The provider had a plan to improve the service’s systems and processes. The provider was working closely with local authority partners in the development of their service improvement plan.
Right Care: People received person-centred care. Staff respected people's rights and treated them with privacy and dignity. People had care plans and risk assessments in place, however, these were not always up to date. This meant people were at increased risk of not always receiving safe care and treatment. The registered manager was open and transparent about work being done to update care plans and risk assessments. The registered manager had a plan to ensure care plans and risk assessments were routinely reviewed and kept up to date.
Right Culture: The culture of the service supported people and staff in an inclusive way; enabling people to live their day-to-day lives as they chose to. Staff told us that the culture of the service had greatly improved as a new team had been formed. However, quality assurance systems to assess and monitor the service were not always being routinely used and CQC was not always being sent notifications as required. Notifications are communications informing CQC about events the provider needs to tell us about. This meant the provider did not have enough of an oversight of the service to ensure it was being managed safely and quality maintained. Therefore, we could not be assured people always receive high quality care. The registered manager had a plan to ensure the necessary quality assurance systems were in place.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was good (published 10 September 2019).
Why we inspected
We received concerns in relation to governance, care planning, risk management, health action plans, mental capacity assessments and best interest decisions, staffing and medicines management. A decision was made for us to inspect and examine those risks. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.
The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.
We have found evidence that the provider needs to make improvements. Please see the safe and well led sections of this full report.
You can see what action we have asked the provider to take at the end of this full report.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Gibraltar Road Nursing Home on our website at www.cqc.org.uk.
Enforcement
We have identified breaches in relation to good governance at this inspection.
Please see the action we have told the provider to take at the end of this report.
Follow up
We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.