During an assessment under our new approach
Date of assessment 6 February to 20 March 2025. Gabriel court is a care home without nursing. At the time of our assessment there were 17 people using the service. As part of our assessment activity, we undertook an on-site visit on 6 and 27 February 2025. This assessment was carried out by 2 inspectors, a regulatory coordinator and 2 Experts by Experience who have personal experience of using or caring for someone who uses this type of care service.
During this assessment we spoke with people, and their relatives or advocates, and visiting professionals. We also spoke with 7 staff including the nominated individual, registered managers, deputy manager, care staff and the wellbeing and activity coordinator.
This assessment was prompted by information we held about this service. We assessed a total of 33 quality statements. At our last inspection the service was rated inadequate.
The provider was previously in breach of the legal regulation in relation safe care and treatment and governance. Not enough improvement was found at this assessment, and the provider remained in breach of these regulations. During this assessment, we found several concerns with the quality and safety of people’s care and we identified a breach in staffing.
The overall rating of this service has changed to requires improvement.
This service has been in Special Measures since 20 December 2024. The provider demonstrated some improvements that had been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.
Accidents and incidents were not always well managed. Improvements were needed to analyse for trends and patterns to prevent future incidents. The provider had not always complied with conditions imposed on their registration to keep people safe. Information was not always fully recorded for sharing with other services such as emergency care. People were not always protected from the risk of harm, concerns of low level neglect were reported from relatives and commissioners. Risks to people were not always mitigated as care was not consistently delivered as planned. Equipment was not always used safely by staff. Staff recruitment and training needed improvement to ensure only suitable staff were employed and staff had the skills and knowledge needed to provide good quality, safe care. There had not always been enough staff to support people safely. This had improved due to a restructure of the service and redeployment of staff. Medicines were not always managed safely. Safe storage of medicines needed improvement and staff had not always taken appropriate action when medicines were missed. Soap and paper towels were not available in all rooms for staff handwashing, but personal protective equipment, such as gloves and aprons, were available and used. The home was visibly clean and odour free. There was limited evidence of people being part of the wider community and enjoying activities away from the home. People chose how to spend their time and suitable activities were provided inside the home.
The provider had not always worked well in partnership with other stakeholders to drive improvement. Systems and processes had not been consistently effective in identifying and actioning risk and quality concerns.
Consent was sought from people before delivering care and refusals of care were respected. Mental capacity assessments were completed where needed and deprivation of liberty safeguards were applied for or in place appropriately.
The building was mostly safe and improvements had been made since the last inspection to reduce risks such as scalding and fire safety concerns. Regular safety checks took place and personal emergency evacuation records were in place for people. People had regular access to a GP and referrals were made where needed to other professionals.