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Gabriel Court Limited Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 27 August 2020

About the service

Gabriel Court is a residential care home separated into two units providing personal care to up to 44 people. One unit is the lower dependency unit and the other is the higher dependency unit, where people with more advanced dementia are cared for. At the time of our inspection there were 38 people using the service.

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

Medicines were not always safely managed. As a result, three people had not received their medicines as prescribed and stock control systems required improvement.

The provider had quality control systems in place, however they were not always effective as records were not always correct and audits had not always identified errors in records.

There were enough skilled and experienced staff to meet people’s needs. Staff were adequately trained and had regular competency checks. Staff told us that they felt supported by the management team.

People’s individual risks were managed in a safe way and staff knew how to protect people from the risk of harm and abuse. Risk assessments were completed appropriately, for example around nutrition, pressure sores and mobility.

Care records were person-centred and contained sufficient information about people’s preferences, specific routines, their life history and interests.

People and their representatives were involved in the planning of their care and given opportunities to feedback on the service they received. People’s views were acted upon.

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

The last rating for this service was inadequate (published 5 June 2020) and there were breaches of nine regulations. We placed conditions on the provider’s registration whereby they were required to send monthly reports on the improvements they had made. At this inspection improvements had been made, however the provider was still in breach of regulations so the conditions remain in place.

Why we inspected

The inspection was prompted in part due to concerns received about the management of medicines, moving and handling practices and wound care. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from inadequate to requires improvement. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvement. Please see the safe and well-led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Gabriel Court Limited on our website at


We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified two breaches in relation to the management of medicines and the accuracy of records at this inspection. We also found that when the provider identified that improvements were needed, action plans were not always created to evidence that the required improvements were being addressed.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will contin

Inspection areas


Requires improvement

Updated 27 August 2020

The service was not always safe.

Details are in our Safe findings below.



Updated 27 August 2020


Requires improvement

Updated 27 August 2020


Requires improvement

Updated 27 August 2020


Requires improvement

Updated 27 August 2020

The service was not always well-led.

Details are in our Well-Led findings below.