You are here

Gabriel Court Limited Inadequate

We are carrying out a review of quality at Gabriel Court Limited. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary

Overall summary & rating


Updated 5 June 2020

About the service

Gabriel Court Limited is a residential care home for up to 44 older people living with dementia. At the time of inspection there were 40 people living at the home.

People’s experience of using this service and what we found

There was a registered manager who had been the manager of the service since it registered with CQC in October 2010.

The provider failed to have adequate systems to assess, monitor and mitigate the risks to people’s health, safety and welfare. The provider had not kept up to date with current legislation to keep people safe.

The provider failed to have systems and processes to assess, monitor and improve people’s quality and safety of care. They failed to have quality monitoring of all areas to identify where people were not receiving care that met their needs.

The provider failed to have systems to safeguard people from abuse or improper treatment. People were not always treated with dignity and respect.

People, their relatives and representatives had not been involved in the planning of their care. People’s feedback and complaints had not been used as learning or used to improve the quality and safety of care.

There were not enough skilled and experienced staff to meet people’s needs. Staff were not adequately trained, and their competencies had not been checked. Staff did not receive the support and supervision they required to carry out their roles.

The provider failed to update peoples’ risk assessments and care plans regularly or as their needs changed. They failed to have a safe handover system to ensure staff had information about people’s current needs.

People did not always receive food and drinks in a safe way or that met their needs. People did not always receive care that had been recommended by health professionals or receive their medicines as prescribed.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

People had access to indoor and outdoor communal areas. Staff were recruited using safe recruitment practices. Staff understood when to seek medical advice.

For more details, please see the full report which is on the CQC website at

Rating at last inspection

The last rating for this service was Good (published 26 August 2017).

Why we inspected

This was a planned inspection based on the previous rating.


We identified nine breaches of regulation in relation to safety of the environment, safeguarding, staffing, nutrition, consent, respect, person centred-care, complaints and governance. Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan for 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the

Inspection areas



Updated 5 June 2020

The service was not safe.

Details are in our safe findings below.



Updated 5 June 2020

The service was not effective.

Details are in our effective findings below.


Requires improvement

Updated 5 June 2020

The service was not always caring.

Details are in our caring findings below.


Requires improvement

Updated 5 June 2020

The service was not always responsive.

Details are in our responsive findings below.



Updated 5 June 2020

The service was not well-led.

Details are in our well-led findings below.