Archived: Gables Care Home

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 assessment we rated this key question inadequate. At this assessment 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.

Improvements had been made since the last inspection, and they were no longer in breach of legal regulations in relation to safeguarding people from harm and abuse, and duty of candour. Improvements had been made in relation to good governance however they remained in breach of legal regulation in relation to regulation 17. There was limited evidence of people’s involvement in care plans and risk management. Staff had not received appropriate supervision until recently and annual appraisals had not taken place.

This service scored 56 (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 and honesty. Lessons had not always learnt to continually identify and embed good practice.

The current manager was working to develop a culture of learning and embed good practice however this needed to be fully implemented and sustained. Staff comments included, “Manager explains things and makes me feel comfortable” and “He asks what we need and what we think needs to change and supports us with it.”

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety.

Inconsistencies and gaps in care records, risk assessments and medicine records meant continuity of care and monitoring of safety was not robust.

The manager worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

Staff were knowledgeable around safeguarding and said they felt able to raise concerns and had confidence the manager would act appropriately.

The provider did not always work well with people to understand and manage risks.

Risks to people were assessed, however there remained some inconsistencies and discrepancies. There was no evidence the provider had worked to develop and improve the involvement of people, or their representatives in care planning, risk management or reviews since the last inspection.

Staff knew people well and worked with them to meet their needs in a safe and supportive manner.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The first floor of the home was not occupied. Work had been completed to ensure window restrictors were compliant with the Health and Safety Executive (HSE) guidance. People could have gained access to the stairs leading to the first floor as the door did not close securely. Trigger points in the fire alarm were not always checked weekly in line with the provider’s policy. We raised this with the manager during the inspection.

Internal decoration of bedrooms had started; however, the exterior of the property needed improvement. A relative said, “The outside needs improving I think.” Another relative was working to improve the garden area for people and was happy to do this, however there was limited evidence of investment from the provider.

Necessary servicing and checks on equipment had been completed.

The provider did not always ensure safe recruitment practices were followed and did not make sure staff received effective support, supervision and development.

One staff member had started in post before their DBS check had been returned. There was no reference from their previous employer and references received pre-dated their application form. Gaps in employment history were not explored.

Staff had not received support and supervision in line with the provider’s own policy. Staff had attended supervision meetings in March 2025 and a plan was in place for appraisal and supervisions to be completed regularly moving forward.

Relatives commented, “In the last 6 months I always see regular care staff” and “There doesn’t seem to be a problem [with staffing levels].”

The manager and staff assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The home was clean and tidy. Two staff had lead roles as infection prevention and control (IPC) champions and effective IPC practices were observed. Food storage and labelling of foods had improved. Some cutlery needed to be replaced as it appeared to be old and dirty. Wall dispensers containing hand gel were in use however this had not been risk assessed. Relatives commented on the cleanliness of the home saying, “The rooms are clean and tidy” and “When we go there’s always a cleaner around.” Another relative commented, “They are gradually doing it up, bit by bit.”

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Guidance was available for creams applied by care staff as part of personal care; however, records were not fully completed. Patch application records did not always demonstrate rotation in line with manufacturers guidance to prevent side effects.

Some people were prescribed medicines to be taken on a ‘when required’ basis or with a variable dose. Information for how these medicines should be administered was now in place, but some needed further person-centred detail.

Systems were in place to make sure people’s medicines were administered safely. Medicines that needed to be given at specific times were given correctly.

People’s medicines allergies were recorded accurately.

Medicines were stored securely including controlled drugs. Temperatures were recorded for the medicine rooms and fridges; however, the fridge maximum temperature had been out of range and had not been investigated to ensure medicines were safe to use.

We observed medicine administration to two people; staff were respectful, and people were given the time they needed.

Comprehensive policies and procedures were in place to support the administration of medicines. Medicine audits were completed regularly and had identified some of the issues we found.