The Gables

On this page

• 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 inspection we rated this key question good. At this inspection the rating has 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 regulation in relation to safe care and treatment and the premises.

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 based on openness. The management team and staff were not always aware of potential risks resulting from the physical environment and therefore failed to act or learn from them. For example, the management team did not identify or address concerns regarding poor infection prevention and control practices throughout the service. The management team were not fully aware of the potential risks from freely moving wardrobes and therefore failed to act to reduce the risk of harm. The provider did not demonstrate a learning culture where they were attuned to potential safety risks or acted pro-actively to reduce the potential for harm. However, when incidents, accidents or significant events occurred the provider investigated these to see if any lessons could be learnt. For example, following a person falling, the provider reviewed their instructions to staff on how to safely and effectively support the person until additional support arrived. One healthcare partner told us staff usually shared information about safety events as needed when they arrived on site. The manager also maintained contact with the team via email to ensure timely communication regarding any incidents or concerns. They went on to say when required, the manager or senior carer was able to provide up to date records regarding the person.

The provider did not always work well with people to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. There was contradictory information on some people’s care and support plans and risk assessments. We also saw examples where 1 persons known interactions and non-concordance with personal care was not accurately recorded or assessed. This put them at the risk of having inconsistent care should they move between healthcare services as their needs were not fully recorded or effectively planned. However, we saw other instances where people’s individual needs changed, and they were referred to other healthcare providers without delay. One person described how well the provider managed their care and liaised with other healthcare partners to ensure they received a coordinated approach. They went on to tell us they found this useful. A healthcare partner told us they felt staff were responsive when issues were raised and the senior carers always appear to know people well.

The provider did not always work well with people to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from avoidable harm and neglect. The provider did not always share concerns quickly and appropriately. We found a situation where someone had been subjected to unacceptable conditions in their bedroom, which potentially could impact on their emotional wellbeing and physical health. However, neither the management team, nor the staff, could demonstrate they had acted appropriately to safeguard this person. Despite staff and the management team receiving training on safeguarding and being able to demonstrate a good degree of knowledge on how to respond to concerns, they failed to do so in this instance. We passed our concerns to the local authority for their attention.

The provider did not always work well with people to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. There was contradictory information on some people’s care and support plans and risk assessments. We also saw examples where 1 persons known interactions and non-concordance with personal care was not accurately recorded or assessed. This put them at the risk of having inconsistent care should they move between healthcare services as their needs were not fully recorded or effectively planned. However, we saw other instances where people’s individual needs changed, and they were referred to other healthcare providers without delay. One person described how well the provider managed their care and liaised with other healthcare partners to ensure they received a coordinated approach. They went on to tell us they found this useful. A healthcare partner told us they felt staff were responsive when issues were raised and the senior carers always appear to know people well.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment and facilities supported the delivery of safe care. Some parts of the building were unsafe. We saw items, including a step ladder and a disused radiator, were unsecured in the upright position and accessible to people. These were a risk of toppling. We saw the provider had failed to risk assess free standing wardrobes. These freely moved when touched and were accessible to people, including those with varying degrees of mobility, and presented a risk from toppling and crushing. In the communal area there was an extension lead on the floor presenting a risk from tripping. A radiator and a pipe leading to a radiator were uncovered. These issues presented a risk of harm from contact with a hot surface. We saw food and drinks thickeners were unsafely stored in the lounge area. These areas were accessible to those living at The Gables, including those living with dementia. This presented a risk of asphyxiation and choking as they were unsafely stored. These issues put people at the risk of avoidable harm.
The provider did have checks in place for the management of risk from fire and completed regular checks to ensure their systems were working and safe. One healthcare partner told us, “The lounges were pleasant, with seasonal decorations and displays of residents’ activities." They went on to say when a problem with a bed was reported, maintenance attended promptly and resolved the issue. Staff assured visiting professionals that concerns would be acted upon.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support and development. They worked together well to provide safe care that met people’s individual needs. We saw instances where staff were readily available to support and assist when needed. One person told us staff answered call bells in a timely way. The provider followed safe recruitment checks when employing new staff. Staff felt they received an appropriate amount of support and supervision to assist them in delivering care.

The provider did not effectively assess or manage the risk of infection. They did not effectively detect and control the risk of it spreading or share concerns with appropriate agencies promptly. One person’s bedroom was unsanitary and presented a risk to their health and welfare. The management team told us this room had been cleaned. However, we saw extensive evidence of unknown substances including dried on fluids on the bedroom’s vanity unit, walls and radiator covering. A member of the management team confirmed these substances were bodily fluids. Exposure to these fluids presented a risk to the health of the person using that bedroom. We passed our concerns to the local authority for their consideration and to keep the person safe.

The provider failed to ensure clinical waste was safely stored. We saw the clinical waste container was poorly marked, unlocked and located in the garden area and accessible to those at The Gables, including people living with dementia. The container contained unbagged clinical items, including urinary catheter’s and open access to bodily fluids. This presented a risk to the health of people accessing this area.

The provider failed to evidence they had acted when potential concerns were identified regarding the management of legionella. Legionnaires' disease is a serious type of pneumonia caused by Legionella bacteria. They had received a report in 2023 recommending the removal of ‘dead leg’ pipes. These were pipes where stagnant water can gather increasing the risk of legionella. In 2024 the providers water sampling identified the need for investigation and further tests. At the time of the inspection the provider failed to evidence they had acted in either instance. This put people at the risk of harm from communicable illnesses.

We passed our concerns to the local authority’s environmental health department for their consideration.

In other areas of the home, we saw some over chair tables were worn and showing signs of fluid ingress which hampered effective cleaning. We saw people were eating and drinking from these tables. We saw dried fluids and food debris on the underside of dining chairs indicating poor cleaning practices.

These issues put people at the risk of harm from communicable illnesses. Following us raising our concerns the provider commenced work to address the issues including, redecoration of 1 person’s room, new clinical waste storage and the removal of dead leg pipes.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People told us they received their medicines as prescribed by a trained and competent staff team. However, we saw instances where further information was needed in people’s records to ensure they received their medicines safely. For example, where people needed their medicines to be given covertly for example crushed and, in their food. The provider had not ensured information around individual medicines was up to date. Further information was needed regarding the administration of PRN (As required) medicines for the management of diabetes. For example, there needed to be clearer instructions on what medicine to administer, when and why, to ensure people received safe and consistent support. Following our visit the provider informed us they had taken steps to ensure the correct documentation was in place.