Gwendolen Road 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

We reviewed all quality statements in the Safe domain. Since the last inspection the quality and detail of information within risk assessments and care plans had continued to improve, which meant staff had access to clear guidance on the care of people’s needs to improve both the safety and quality of care provided. Systems and processes for monitoring and responding to risk enabled the management team to identify themes and trends, and therefore prevent and mitigate risk. Effective processes and training of staff in safeguarding supported people to live in safety. Systems and processes monitored and promoted people’s health, supported by good partnership working. Staff were recruited safety, and there were sufficient experienced and skilled staff to meet people’s needs. Systems and processes, along with staff training meant people received their medicine as prescribed. Minor environmental concerns identified at the time of the assessment were actioned by the provider, with additional checks being introduced to maintain the improvements undertaken. Equipment was maintained and inspected by external companies.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People and relatives told us communication was good, and they were kept informed about any changes regarding, safety including incidents or accidents. A family member told us, “They keep in touch if there’s anything serious. Last year he had a fall and had to go to hospital.”

The registered manager spoke of the action taken, and of future planned improvements in response to areas identified for improvement at the previous inspection and in response to partner agency feedback. Staff spoke of how the service had improved over the last 12 months, which were attributed to the new management structure put in place. A staff member told us, “The service is far better managed now and this has meant staff are more confident, and people receive better care in my view.”

The provider had processes to record accidents and incidents, which were reviewed by a manager. An accident, themes and trends tracker was in place so reoccurring events could be identified and acted upon, and shared with the staff team.

People told us they could access healthcare and other services they required, and were supported to do so. One person said, “Staff always come with me to medical appointments.”

Managers told us about the work they had undertaken to improve relationships with partner agencies and healthcare professionals. Staff told us how they contacted healthcare professionals such as GP’s and dietitians in response to changes in people's need.

We received positive feedback from partner agencies, which included the management of the transition process for a person moving into the service. We saw a written compliment from a G.P. in relation to the alertness of staff in noting the deteriorating medical condition of a person, and staffs response to the recommendations made and follow up actions.

Systems and processes for safe partnership working had been reviewed and changes made to support the safe transition of people moving into the service.

People and relatives told us the service was safe. A person told us, “I feel very safe here, staff protect me and they are always around if I need them.” A second person said, “I feel safe living here.” A relative told us, “It’s absolutely safe there.” Safeguarding was discussed at resident meetings. A relative spoke of their awareness of legal restrictions imposed through a Court Order.

Staff said they were confident in speaking up if they had any concerns, which was supported by an open line of communication with managers. Staff told us they were listened to; concerns were taken seriously and action taken where required. Managers told us they reviewed all incidents, including safeguarding concerns and shared any learning or changes to procedures or processes with staff. Following our assessment the registered manager informed us they had displayed within the service information about safeguarding in a range of formats to meet the needs of people, which included alternate languages to English and an easy read version.

Staff supported people consistent with their risk assessments and care plans to promote people’s safety. We saw a person respond to a staff member with smiles and tactile touch. Staff interactions with people were positive, respectful and compassionate.

Staff said they were confident in speaking up if they had any concerns, which was supported by an open line of communication with managers. Staff told us they were listened to; concerns were taken seriously and action taken where required. Managers told us they reviewed all incidents, including safeguarding concerns and shared any learning or changes to procedures or processes with staff. Following our assessment the registered manager informed us they had displayed within the service information about safeguarding in a range of formats to meet the needs of people, which included alternate languages to English and an easy read version.

People said they felt safe, and spoke of the support they received from staff to manage risk, and of being able to make their own decisions and choices. One person said, “I have a lot of involvement and choice in my life.”

Managers were confident the processes for managing risk were robust. They talked us through the assessment process, the development of the initial and long term development of care plans and risk assessments and their continual review. Throughout the process, managers said people and their relatives were involved, and where required external agencies and professionals provided support. Staff were aware of the action to take in the event of an accident or incident. Staff were confident and knowledgeable as to how people’s risks were to be managed, which included responding to accidents and incidents, and the seeking of medical advice.

People were supported in the least restrictive way possible. People’s safety was promoted, where commissioned, staff provided 1:1 or 2:1 to support. Staff sat with people at mealtimes where there were potential risks to their safety.

Risk assessments and care plans were in place, which supported staff in the delivery of safe care. Assistive technology was used to reduce risk of falls such as motion sensors. A new software system had been introduced, which enabled to staff to record the care and support they provided as and when the care was delivered, which included changes to people’s needs, risks or concerns. Managers had oversight of the system and were able to act promptly to any changes or risks in people’s care and safety. Processes were in place to record accidents and incidents, which were analysed to identify patterns and themes, so action could be taken to reduce risk.

People told us they were happy with the environment. They said they were satisfied with how their rooms had been organised and of their access to the outside spaces. A person told us, “The furnishings in my room are all mine, and my family have painted my room for me. I like the décor and furnishings around the home.” However, some relatives said they would like to see improvements to the garden. A relative said, “The garden needs doing up.”

Managers told us they carried out regular checks of the premises, which included monthly audits. Staff told us where repairs were needed these were undertaken promptly by the maintenance team.

A small number of environmental safety concerns were noted when we visited. These included a threshold step from a corridor to the garden, which required lowering for safe entry and exit, some units in communal areas required securing to the walls, and in the garden we noted loose bricks and slabs. The issues we identified were addressed promptly by the provider.

The process of auditing the environment was not sufficiently robust. Areas we identified requiring improvement had not been identified by the management teams monthly audits. The content of audits was updated in response to our feedback. A WhatsApp maintenance group and maintenance book enables staff to alert the maintenance person of any concerns they have noted within the service. Records showed systems and equipment were maintained and inspected by external companies to promote people’s safety, including gas, electrical, fire, passenger lifts, and moving and handling equipment.

People said there were enough staff, including people who required 2:1 and 1:1 support. One person told us, “I receive all the care I need from the staff.” A second person said, “There are always enough staff around to assist me if I need it, during the day and night.” Relatives we spoke with raised no concerns about staffing levels. A relative said, “There are plenty of staff, every time I call the bell they come when I visit.”

A manager told us they had a full complement of care and support staff. The manager advised they were looking to support the development of staff through the introduction of lead roles within the staff team, to be known as 'champion roles', including an 'activity champion.' Staff told us there were enough staff to meet people’s needs and keep them safe. A staff member told us, “I’m happy with the numbers of staff we have. We’re not rushed and if something happens, managers and senior staff always step in to help.” Staff told us they received the necessary training to meet people’s needs and keep them safe. Staff told us they were supported to do their roles, through supervision and appraisals.

Sufficient staff were deployed. Staff were continually able to support people when they required assistance. Staff interactions with people were positive. It was clear staff knew people well. We observed multiple interactions between people and staff all indicating good rapport and trust. This included for people who had limited speech and vocabulary and who spoke languages other than English.

Staffing numbers were kept under review and were based on the needs of people, with consideration being given to the skill mix of staff required. Short notice staff absence was managed by the use of agency staff. Processes were in place to support safe recruitment practices, including induction and training. Regular supervision and ongoing monitoring of staff provided an opportunity to discuss performance and any learning and developmental needs. Staffing numbers were kept under review and were based on the needs of people, with consideration being given to the skill mix of staff required.

People told us staff wore personal protective equipment. A person told us, “Staff wear plastic gloves when assisting me. A relative told us, “Staff wear PPE. I’ve seen them wearing those disposable aprons.” Relatives spoke positively of the cleanliness. A relative said, “The home is very clean, there’s no smell at all.”

Managers carried out daily checks to ensure the service was clean and staff were following safe policies and procedures for the prevention of infection such as effective handwashing. Staff told us they had access to personal protective equipment such gloves and aprons. A housekeeper told us, “I have enough of the right equipment and products to clean rooms and communal areas.”

All areas of the service were clean and fresh. Staff wore personal protective equipment and disposed of waste safely. We observed clinical waste bins were unlocked on the second day we visited, and were closed on other days. In response, checking of security of clinical waste bins was incorporated onto the Health and Safety checklist and walk around.

Systems and processes assessed and managed the risk of infection and promoted people’s safety, health and wellbeing. Audits and spot checks with regards to cleanliness were conducted, and any shortfalls were identified with action taken. Housekeeping staff completed cleaning schedules. All the provider’s practices were undertaken in line with their infection prevention policy.

People told us they received their medicines at the right time and in the right way. A person told us, “Staff help me with my medication, which is always given on time, and wear plastic gloves. They always explain to me what the medication is for.” A relative told us, “Staff sort out her medicines for her.”

Managers told us medicine management was safe and robust, supported by protocols to identify and manage and concerns. We spoke with staff about medicines. A staff member told us, “We have strict processes with medicines here, such as managing people’s controlled drugs. (a drug or other substance which is tightly controlled by the government because it may be abused or cause addiction.) We have a handover at the start and end of every shift to check everything is okay. We receive competency checks from the manager, and they do audits of medicine.”

The provider’s role in relation to people’s medicines was clearly detailed in relevant policies, procedures, and training. Current and relevant professional guidance about the management of medicines was followed. Medicines were given as prescribed and recorded and stored securely consistent with the policy. People were given their medicines safely and at the right time. Staff had training in the safe management of medicine, and had their competency assessed.