Archived: Gabriel Court Limited

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• 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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question inadequate. At this assessment the changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulations in relation to people’s safe care and treatment and staffing at the service.

This service scored 47 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety. They had not listened and learned from concerns about safety. There was evidence they had not consistently complied with conditions imposed on their registration by the Care Quality commission [CQC] to ensure people’s safety.

There was evidence the provider had left communal areas unattended that should have been under staff supervision, resulting in a number of unwitnessed falls. The provider did not learn from these incidents or identify the trends and patterns that evidenced falls were happening at a time when less staff were on duty to be able to supervise communal areas and meet the needs of other people in the home. The provider did not increase staff numbers to ensure supervision of communal areas despite concerns raised by both the local authority and CQC. They continued to leave the communal areas unsupervised, breaching the conditions of their registration, exposing people to increased risk of harm as unwitnessed falls had continued. At the time of our site visit one of the home’s units had closed, people had been moved and staff redeployed to the remaining unit. This had increased staff numbers to communal areas and mitigated risk to people.

An accidents and incident tracker was in place which included tools to identify times of day and area of the home incidents took place in to support identifying trends and patterns. The provider would need to ensure this was used appropriately and embedded in practice. Where internal investigations had taken place, reflection and lessons learned to prevent future incidents were recorded.

The provider had not always worked well with people and healthcare partners to establish and maintain safe systems of care. They had not always made sure there was continuity of care for when people moved between different services. The provider had a system for transition between services; however, we were not assured this always worked well. For example, a safeguarding was raised by the hospital when a person was found to have several pressure sores that had not been communicated on transition into the service. This meant hospital staff did not have information about how the persons wounds were managed.

People were in the process of being moved to other homes. The registered manager and staff were working with other providers to facilitate assessment visits, share information and help people pack for their move.

People were not always protected from the risk of harm. There were concerns raised from family and professionals about neglect. A relative told us that the local authority had raised concerns about the safety of their relative’s skin with them as they had not been supported with personal care as planned. Another relative told us, they had seen a decline in the level of care provided. They said, “I don’t think anyone would deliberately hurt [person], it’s more low level neglect.” A medical professional and other professionals had raised concerns about neglect with CQC which were reported to safeguarding. We found pressure area care was not consistently well supported and a good standard of care was not always provided.

We were not assured that Disclosure and barring checks [DBS] were always completed prior to staff joining the service. DBS checks help employers make safer recruitment decisions by checking staff’s criminal record. We found 1 DBS that had not been issued until almost 2 months post start date, the DBS included a criminal conviction that the provider failed to risk assess and implement measures to mitigate the risk to people in the service.

Most staff had received training in safeguarding adults. However very few staff had completed training in safeguarding children and young people. This is particularly important to ensure they are protected from harm, abuse and neglect while visiting the home. People told us they felt safe with staff. One person said, “I feel safe when staff are around, when I ring the bell they come quickly. Another person said, “The carers are helpful and kind.”

Risks to people were not always well managed. Individualised risk assessments were in place with some containing good detail and guidance for staff. However, some lacked detail of the measures to mitigate risk. For example, 1 person was assessed as fully able to use the call bell independently, but the assessment also included that although able, they did not use the call bell to alert staff. This had not been considered as a risk therefore there was no detail or guidance for staff on how else the person would contact staff or how often they should be checked upon to ensure they were safe and their needs were met. The same person was at high risk of pressure sores and had lost some weight but we observed them being offered foods on both of our site visits that were recorded as disliked in their care plan. They ate very little on both occasions and described their meal as, “Inedible.”

We were not always assured that care was delivered to mitigate risk. For example, people were not always repositioned on time or supported with enough fluids to reduce the risk of and support the healing of pressure sores. There was some evidence of deterioration of existing pressure sores or new wounds developing. Oral care was not always supported or encouraged to reduce the risk of tooth decay and chest infections. People had not consistently been supervised in communal areas which had resulted in unwitnessed falls.

People had personal emergency evacuation plans [PEEPS] in place that reflect people’s current needs and gave staff and emergency services clear guidance on how best to support them to escape safely.

The environment was not always safe. We found that heavy furniture was not fixed securely to a wall for 1 person who was mobile and at risk of falls. Another person was found to not have the breaks engaged on their bed and some people did not have the breaks on their wheelchairs engaged when sat in communal areas or when being transferred from chair to wheelchair. Thickening powder prescribed to thicken people’s fluids who were at risk of choking was found to be open and stored in a communal lounge where vulnerable people could access it and could choke if ingested. We highlighted these concerns to the registered manager who took action and addressed them with staff.

Since our last inspection the provider had mitigated the risk of scalding from exposed pipes by ensuring they were adequately covered, and equipment was no longer charged in people’s rooms which reduced the risk of electrical fire.

Regular fire alarm tests took place; fire extinguishers were available and serviced regularly. Fire exits were operating effectively, and escape routes were clear of clutter and debris. Fire doors on people’s rooms were in good condition with working automatic closures.

The provider had not consistently ensured staff were recruited safely in line with regulatory requirements. Previous work history was not always fully completed and gaps in employment were not always explored. Inductions were not always completed to ensure staff had the skills and support needed when first joining the service. Some staff files included retrospective information about their initial training, therefore we were not assured staff had received adequate training when first employed. The risk to people had been somewhat mitigated as there were other experienced staff in the home to offer support where needed to new employees and a number of staff had had previous experience in similar roles.

We were not assured that the home had always been adequately staffed. However, at the time of our site visit some people had moved from the home. The provider had made the decision to close one of the home’s units prior to a full closure of the home and had moved people and staff across to one unit. This meant the communal areas were supervised with adequate numbers of staff to keep people safe until they were moved to new homes. The provider agreed to keep staff numbers and deployment under review until the full pending closure of the home to ensure that people’s needs were met, and they were safe.

Staff training required improvement to ensure staff had the skills needed to provide safe high quality care. A high number of staff had not completed some areas of training including General Data Protection Regulation (GDPR) and how to handle complaints. Almost half of staff had not completed sepsis training, care planning or mental health training. The provider was aware this was an issue and had offered incentives to staff to complete training and had a disciplinary procedure in place for staff that continued to not comply.

The management team completed regular out of hours spot checks of the home and staff team, this gave staff working out of office hours the opportunity to speak with management or seek guidance.

People were not always safe from the risk of infection. Cleaning records did not evidence that cleaning was always taking place as scheduled, however, we observed the home to be visually clean and free from odour. People told us the home was clean, and their rooms were cleaned regularly. One person told us their carpet had been replaced with and easy clean surface they said, “I like the room, its clean and easy to clean.” We found 6 people’s rooms did not have soap and paper towels for staff to wash their hands after supporting people and we found one person did not have a label in their manual handling sling to ensure exclusive use. This increased the risk of cross contamination. There was an increased risk of people consuming food that was not safe. Although opened food was covered and labelled appropriately fridges were for domestic use with temperatures frequently recorded as high. There was no evidence of action taken to address this.

The risk of legionella in the home was reduced. There was a risk assessment in place and regular flushing of pipes in unused areas. Water was stored at safe temperatures. Clothes were laundered safely to prevent cross contamination, and the laundry room was cleaned regularly. PPE was available throughout the home for staff use.

Medicines were not always managed safely. We found that where medicine was missed, guidance was not always sought from a medical professional on possible side effects or complications that could be experienced by people. We were not assured that medicines were always stored in accordance with best practice guidance. For example, we found where fridge temperatures were higher than recommended there was no evidence of action taken and medication room cleaning charts did not evidence that cleaning was always taking place as scheduled. Medication profiles were in place for people and included guidance for staff on how people liked to take their medicine. People received their medicine from a trained senior member of the team, we observed medicines being given safely and in line with best practice.