Archived: Gabriel Court Limited

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question inadequate. At this assessment the rating has changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to governance at the service.

This service scored 39 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not have current information on the providers vision, values or strategy. We were not assured a strategy had been developed through a structured planning process in collaboration and co-production with people who use the service, staff, and external partners. The providers statement of purpose had not been updated for several years despite 2 changes to registered manager and a change of nominated individual. A statement of purpose describes what the provider does, where they do it and for whom they do it for. It is a regulatory requirement that a statement of purpose is kept up to date and submitted to us.

Policies and procedures were in place and in line with current best practice guidance around equality and diversity. Staff told us that the provider and management team were open to listening to staff views, and there was an open door policy.

We were not assured leaders always had the skills, knowledge, experience and credibility to lead effectively, or that they did so with integrity, openness and honesty. The provider had not ensured the conditions of their registration were consistently met, despite being advised on several occasions that this was a prosecutable offence. Considering the providers decision to close the home, CQC did not take further legal action on this matter.

A registered manager was in post; however, they and the provider had been unable to make the necessary improvements to the quality and safety of the home to achieve a good rating and compliance with contractual agreements in place via local authority contracts.

The was evidence of poor communication between the provider and management team which meant they had arrived to meetings with stakeholders unprepared and lacking information.

The provider fostered a culture where staff felt they could speak up. The provider had a whistleblowing policy and procedure in place for staff support and guidance. Staff told us they would be confident to speak up if they had concerns and they felt they would be listened to. One staff member told us they found management approachable and easy to speak to. Another staff member said they would be confident to speak up.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture with equality and equity for people who worked for them. The provider had an equality and diversity policy and ensured a fair recruitment process with equal opportunities for career progression. Staff work patterns were adapted to support personal circumstances where needed. The provider had taken part in the staff sponsorship scheme and was committed to helping those staff find alternative placements either within their own network of homes or within the local area on the homes closure.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. The provider had commissioned a consultant who had registered as the nominated individual [NI] for the service. The NI is responsible for supervising the management of the regulated activity provided on behalf of the provider. We were not assured that provider and manager governance systems were effective in driving improvement. For example, the NI had completed a provider review in January 2025 that had identified that handwash and paper towels were not available in people’s rooms, despite this finding and the registered managers daily walk arounds, the lack of suitable handwashing facilities to prevent the risk of infection was found on assessment. The provider review also highlighted that there was a risk of people being able to access fluid thickening powder, this issue remained unactioned and was observed on assessment, therefore an increased risk of choking had continued. The provider had identified a need for management cover over 7 days a week, to ensure continuity of quality particularly during a period of required improvement. This had remained unactioned at the time of the inspection. Provider and registered manager oversight had not been effective in identifying the issues we found during assessment such as safe storage of food and medicines and safe recruitment of staff.

Staff and leaders did not collaborate and work in partnership well with partners to drive improvement. Following our last inspection the local authority had placed a suspension on admissions due to safety concerns, this suspension was lifted once improvements had been made and the local authority continued to monitor the service. The home was unable to sustain improvements, therefore the local authority and Integrated Care Board (ICB) decided to terminate contracts with the provider. All service users were in the process of being found alternative care and accommodation at the time of the inspection.

Staff and leaders had not always ensured people were still part of the wider community outside of the home. The registered manager told us that one person went to a weekly church service another person had a home visit to support their faith. A staff member told us there wasn’t a lot available. There was no evidence that people were taken out into the community to be involved in any social groups, charities or collaborative working with other organisations to ensure community integration. We observed that visiting friends and relatives were welcome at the home.

The provider and management team did not always focus on continuous learning, innovation and improvement across the organisation. They did not always actively contribute to safe, effective practice. The management and provider team had not communicated well with each other or stakeholders. For example, the NI had identified a concern with a person’s medicine being missed for some time and included this on an action plan for submission to CQC. The registered manager had not been made aware of this medication error. Issues that could be actioned quickly such as ensuring soap and paper towels were available and ensuring peoples oral care was completed were left to continue.

Where the local authority quality team had given the provider and manager deadlines for action such as for completing a fire drill following the moving of people into 1 unit of the building, this was not completed by the agreed date.

The provider had been unable to implement and sustain enough improvement and learning since the last inspection to achieve a good rating. The provider had not improved their rating to good for the last 4 consecutive inspections. We were not assured that the provider and management team were working together as a team or with stakeholders to learn and drive improvement.