Gorsefield Residential 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 inspection we rated this key question requires improvement. At this inspection the rating remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. The service was in breach of legal regulation in relation to people’s safe care and treatment due to issues around the safety of the environment.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not always have a proactive and positive culture of safety based on openness and honesty. They did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice. Although the provider had some checks in place to assess the safety of the physical environment, they failed to identify issues which could place people at the risk of avoidable harm. For example, people had unrestricted access to areas of the building which should have been restricted to staff only as they contained hot water systems. This placed people at the risk of avoidable harm.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. People told us they were referred to GP services promptly by staff.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination and neglect. The service shared concerns quickly and appropriately. People felt safe and supported by staff. One person said they knew who to talk with if they were ever concerned about anything. Staff had received training on how to keep people safe from abuse and neglect and information was available to them on how to report any concerns.

The service did not always work well with people to understand and manage risks. They did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Not all areas of the home were designed to promote a dementia friendly environment. This could lead to disorientation and confusion for some people. However, people told us they had assessment of risk specific to them to minimise the risk of injury. One person described how they were provided with mobility aids to reduce their risk of falls. They said, “I’ve been having falls at home. I feel safer here.”

The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. People were not always safe from avoidable harm. We saw people had open access to potentially unsafe parts of the building. Radiators and hot water pipes were not always covered and not all areas of the home had adequate signage in place to direct people in the event of an emergency. These issues put people at the risk of avoidable harm.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. One person said, “They [staff] are all very efficient. I’ve pressed my buzzer and all of them come quickly. I think there’s enough staff.” People and relatives told us they were supported by enough staff to meet their needs.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. Not all areas of the home were maintained in a way which safely supported effective infection prevention and control practices. For example, there were some items of furniture, stair handrails and a balustrade which were worn hampering effective cleaning.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened. People received their medicines as prescribed. One person told us they always got what they needed, “Same time every day. Regular as clockwork.” Staff had received training in the safe administration of medicines and their competency to safely support people was assessed.