Gibson's Lodge Limited

We carried out this assessment to follow up and review progress since the last inspection in July 2022

The provider recognised shortfalls in people’s care records and was working with the local authority to improve care. The provider was open about the difficulties it faced and drew on external support to address them.

At the time of the assessment a new, consultant management team had just started at the service. This was expected to strengthen governance, oversight and leadership capacity.

We saw good examples of kind and caring interactions between people and staff.

However, the provider was in breach of the legal regulation relating to staffing levels, person centred care, the need for consent, safe care and treatment and good governance. The provider had not established effective governance systems to assess, monitor and manage risks to people’s health, safety and welfare. Staff did not consistently assess or manage risks. Care plans lacked clear guidance on managing risks linked to people diagnosed health conditions, and the provider did not carry out robust assessments of people’s needs.

The provider did not ensure staff completed mental capacity assessments and best interest decisions in line with the Mental Capacity Act 2005.

The provider did not ensure the safe management and storage of medicines. Guidance for ‘as required’ (PRN) medicines did not consistently include clear protocols or person-centred information. This placed people at risk of unsafe administration.

The provider did not ensure staff delivered consistently evidence-based care and treatment. People did not always receive meaningful activities. Staff did not review clinical monitoring tools in a timely way.

The provider did not follow safe recruitment practices. The service did not always deploy enough staff to meet people’s needs. People told us staffing levels sometimes affected their care. Staff reported they worked under pressure due to staffing shortages

The provider did not ensure care was consistently person-centred. Staff delivered care in a task-led way. Staff did not always plan activities in line with people’s individual interests or hobbies. Activity plans were not consistently personalised. This limited opportunities for meaningful engagement.

Staff did not always respond to call bells promptly, which meant people’s needs were not always met in a timely way

The provider did not ensure the environment met the needs of people living with dementia. The design and layout did not support people to move around the home independently.

Staff and managers interacted with people in a kind, caring, and respectful way. People spoke positively about staff, although some raised concerns about staffing levels.

In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.

We have also asked the provider for an action plan in response to the concerns found at this assessment.