Gingercroft 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

Action was taken when things had gone wrong. There was more structure in place to record, monitor and analyse accidents and incidents. People were supported by other health professionals, where needed. Staff received handovers – some felt this was not always successful in ensuring all staff were aware of changes in people’s needs, however a new system had been introduced to improve this. People were kept safe. Staff understood their safeguarding responsibilities and there were systems in place to ensure concerns were reported. People had been supported to reduce risks to their health and support needs – care plans were in place and staff knew people well; however, improvements were needed to ensure plans were always up to date and contained enough detail. Professionals were generally complimentary of the service; although 1 felt improvements were needed to increase the amount of detail in some care plans to ensure staff had a complete picture of people’s needs. There were some gaps in records, such as in repositioning records or in blood pressure monitoring for 1 person. Improvements were needed in the environment. Some areas could not always be kept hygienically clean due to their condition. There were exposed pipes in 1 bedroom which could pose a risk. Other checks were made on the building to ensure it remained safe. Improvements were needed to infection control measures in place as we observed some unsafe and undignified practice. The provider was working on an infection control action plan from the external infection control professionals to resolve issues, but this had not yet been fully completed. Staffing levels were monitored although improvements were needed with this; there had been no impact from this, but it had been recognised more staff were needed but this was not yet in place. Medicines were generally managed safely.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

When people had experienced things going wrong action was taken to reduce the risk of things going wrong again. The quality and safety of care was improving following feedback from external agencies and the provider taking action to address things. Therefore, people’s experience of care was improving.

Staff told us action was taken when things went wrong. One staff member said, “There’s no blame for errors, but we get chance to learn from errors.”

The local authority had been carrying out monitoring visits to the home since 2023 to check the provider’s and management team's progress against the service's action plan. Whilst many actions had been completed, work was still ongoing, and it was felt progress in completing and sustaining improvements had been slow. The local authority will continue in their monitoring of the service. There was now more structure in place to review and look at trends relating to accidents and incidents, and these were being more reliably recorded. The provider and management team were learning following input from other agencies. Improvements needed time to embed and show they were sustained.

One person told us the staff were able to support them with certain aspects of their care needs, and staff called for support from other health professionals when this was needed. Another person told us how they were supported to manage their health condition by staff. People also told us there were regular visits to the home by the GP and they were able to speak to them if they felt they needed to. A relative told us they felt well informed when health professionals input was needed for their relative.

A staff member told us they felt handovers between shifts were not always successful as some changes were not always handed over. However, they said the deputy manager had introduced a new handover record which they felt should improve things. A staff member said if health professional support was needed, if this was raised with the registered manager or deputy manager, they were proactive at chasing this.

One professional who worked with the service and had recently reviewed 1 person told us, “During the assessment I provided advice for the home to contact certain professionals that were already involved within the resident’s care such as the district nurses and the manager noted that this had already been done, therefore, the resident was provided with treatment when required.”

People had access to other health professionals. District nurses regularly visited the service to support people and gave instructions for staff to follow to help people get better. However, staff were not always recording they were following these instructions in care records; we found this to be the case for multiple people. For example, 1 person was supposed to have their blood pressure checked every day for 4 weeks. However, there were 5 days out of 15 days in total so far, where this had not been recorded. The deputy manager told us they would remind staff to record this during a staff meeting. Another person needed repositioning due their skin being at risk and their care summary said they were supposed to be repositioned every 2 hours. The records indicated the person was sometimes going much longer times between being repositioned. This put the person at risk of their skin deteriorating.

People told us they felt safe. If people had concerns, they felt able to report these and concerns were investigated.

Staff understood their safeguarding responsibilities. Staff knew of the different types of abuse, how to recognise potential abuse and the need for them to report concerns.

We observed safe moving and handling practices in the home and staff treated people with kindness. People were comfortable in the presence of staff.

There was now more structure in place to review incidents and these reviews completed more frequently. Safeguarding referrals were made where necessary. Concerns were looked into, and safeguarding referrals were tracked to determine the outcomes and any trends.

People were involved in managing their risks, where possible, and staff knew people well to help people stay safe. We observed one person not being supported in line with their care plan while eating, which we go into more detail about in the effective key question. However, the person did not come to harm as a result of this.

Since the last inspection, a new electronic care planning system had been introduced. Some staff felt the new electronic system was an improvement with having information in one place was beneficial and freed up time. Staff knew people's needs. Staff were able to tell us about the risks to people’s health and safety.

We observed safe moving and handling. We observed one person not being supported in line with their care plan while eating, which we go into more detail about in the effective key question. However, the person did not come to harm as a result of this.

An incident we identified at the last inspection regarding an oxygen cannister had still not been reflected as a risk in the person’s care plans. The deputy manager, who had not been in post at the time of the last inspection, agreed to review the person’s care plan and include this where necessary and we saw evidence this was completed. However, a professional told us, “As part of the residents assessment I am required to access their care plans and daily logs for additional information and evidence purposes. I found most of the information to be recorded and all risks assessments were in place. However, based on the discussions had during the assessment some things were not recorded within their care plan.” However, other care plans had been updated following incidents. For example, one person had a fall which staff had recorded on an accident report, the risk assessment was reviewed, and changes made to the person’s care to reduce the risk of a reoccurrence, while taking their choice not to have bed rails into account. Another person sometimes displayed their feelings physically and a comprehensive plan was in place to guide staff how to support the person during these times. Therefore, while there had been some improvements, more improvements were needed to ensure this was consistent and sustained.

People were exposed to risks from the environment, such as exposed pipes in 1 bedroom identified and the risk of the spread of infection due to difficulties with being able to keep the home hygienically clean. However, no one had come to harm as a result of this. Work was ongoing to refurbish the home.

The registered manager told us, and we saw, there were new fire doors fitted and actions from the checks from the fire service were largely complete. The registered manager felt there was only 1 action outstanding, which they said would be soon resolved, and they would await being signed off as complete by the fire service. We will check the fire service are satisfied with the actions taken, once they have checked. Staff told us they felt the home needed decorating.

There were exposed pipes which could become hot in a person’s bedroom. This could cause a serious injury if someone was to come into contact or fall against these. We asked the registered manager to complete a swift review of the entire home to identify any other exposed pipes or hazards which could pose a risk to people. The environment was tired and in need of refurbishment. Some surfaces could not be kept hygienically clean due to wear and tear. Work was ongoing to address the environment. There had been work undertaken to improve the fire safety following feedback from the fire service. We saw window restrictors were in place. There were no malodours in the home.

Checks by appropriate professionals were made on the building, such as electrical and gas safe checks. Environmental audits were in place, which acknowledged the refurbishment work still needed to be completed in numerous areas. However, the risk from hot pipes had not been identified in order to address them to keep people safe. The registered manager agreed to take action to address this following our feedback.

People told us they felt staff knew what they were doing and they did not have to wait long for support. One person said, “If I buzz, they [staff] come quickly. It depends on what else they are doing, of course. They may be dealing with an emergency.” One person said, “They [staff] seem to know how to do things.” Another person said, “I’m well looked after.”

Staff fed back they felt an extra staff member was needed in the morning to be able to support people in a timely manner. The registered manager acknowledged this was being looked into. While agency staff were being utilised to cover permanent staff sickness or annual leave, agency staff were not being used to cover the extra staffing needed. Until the extra staffing was resolved by staff shifts altering to accommodate this, it left the service short staffed. However, no one had come to harm as a result of this. Staff received training for their role. However, there was some mixed feedback from staff. Staff all told us they received training, however multiple felt they would benefit from more face-to-face training, particularly for moving and handling. One staff member told us the deputy had delivered some face to face moving and handling training, but some staff were still some waiting for this. Staff confirmed they had their suitability checked before they started working at the service and told us they had training in their role. The registered manager confirmed they were trying to recruit more staff however this was proving difficult.

While a staff member was not always present in the communal lounges at this assessment, which we found to be the case the last time we visited, there was more regular oversight and staff were entering the lounges more frequently. This meant concerns or people needing support would be identified quicker.

The dependency tool contained an error, so it did not calculate the correct minimum number of staff needed. The provider had more staff than the minimum incorrect calculated by the dependency tool, so there was no impact from this. However, it was not clear how staffing levels were being determined. The deputy manager was trying to find an alternative dependency tool. The registered manager had acknowledged more staff were needed in a morning, and while no one was coming to harm as a result of this, it had not been resolved. Staff were recruited safely. Checks were made on staff suitability to work at the service, such as references from previous employers and checks on criminal records. Staff also had their identity checked.

People told us they felt the home was kept clean. One person said, “Very much so [clean], the cleaners here are very good. They clean my room more or less every day.” People confirmed to us staff wore gloves and aprons when needed. However, while people did not feel the home was unclean, they were exposed to risk as the physical environment and support they received were not always in line with best practice and all improvements identified in relation to infection control had not yet been completed.

Staff confirmed they had access to enough Personal Protective Equipment (PPE) such as gloves and aprons. However, as we observed staff following poor hygiene practices, we could not be sure they would always follow safe infection prevention and control.

We observed people not being provided plates or serviettes when having snacks, so they were having to put exposed food directly on communal tables. Tables were not wiped down between uses. This was not dignified and not hygienic. There was also a communal box of biscuits which was offered to people, however individuals were putting their hands into this box and touching the food. This was not hygienic. Light pull cords in some rooms did not have a coating which could be cleaned, and the cord was dirty, which could pose an infection control risk as they could not be kept hygienically clean.

Action was in progress to address all of the issues identified in the infection control report which had been completed by the local infection prevention and control team. Many areas had been addressed, such as a colouring coding system and separate storage for cleaning equipment and infection control training for staff. However, some actions had not yet been completed such as the replacement of furniture and fittings and the full refurbishment of the environment. The deputy manager had started a new internal infection control audit which also identified areas for improvement. We will check improvements continue the next time we assess the service.

People were supported with their medicines. One person said, “Each day, there’s always 1 member responsible for medicines.” As stock levels matched records, we could see people were getting their medicines as prescribed.

A staff member felt medicines systems had improved since the introduction of the electronic medicines system. One staff member said, “The medicines system is much better, we are much more on top of it.”

Medicines were generally managed safely. There were protocols in place to guide staff about ‘when required’ medicines. Those who needed ‘when required’ medicine to help them calm down, were not having this regularly as other methods to help calm them down had been successful. Records showed staff had their competency checked to ensure they were safe to administer medicines. We observed 1 topical medicine did not have an opening date on, despite it having a 3-month expiry date once opened. No one came to harm as the topical medicine was still in date based on the date of the prescription label, but all medicines with an expiry date from opening should be labelled. We also observed senior staff administering medicines. This was done in an encouraging way and staff asked people how they were feeling and checked consent first. Medicines that had extra checks and stock control measures in place, as well as always being locked away in a specific cupboard, were managed safely. We checked the stock levels and these matched records.