Gabs Healthcare

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 people were protected from abuse and avoidable harm. This is the first assessment for this newly registered service. This key question has been rated inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulations in relation to consent, safe care and treatment and recruitment of staff at the service.

This service scored 38 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice. There was limited evidence of systems or processes in place to review, analyse and learn from accidents and incidents. There was no evidence of systems in place to record and analyse incidents involving people with a learning disability so lessons learned and improvements could be determined and practice improved.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services. There were no systems or processes in place to share information about people’s care and support needs between services effectively. The provider did attend multi-disciplinary team meetings where information was shared but the provided did not have their own independent systems and processes in place to collate, review and share information about people to ensure safe systems of care and support.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to this could be achieved. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately. The provider had a safeguarding policy in place for adults but not for children. The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act (MCA). We found the provider had limited knowledge, understanding and application of the Mental Capacity Act 2005 and was not able to evidence the knowledge, systems or processes required to carry out best interest decision-making processes. Feedback from people and local professionals did not highlight any concerns about safety or unsafe practices and members of staff confirmed they knew how to report any concerns about safety.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs which was safe, supportive and enabled people to do the things which mattered to them. The provider did not have adequate systems and processes in place to identify, assess and mitigate risks to people’s care and support. The provider relied heavily on care plans and assessments carried out by members of a multi-disciplinary team linked to the provision of care for a single person. The provider did not have a systematic approach to care planning and risk assessment which could be applied to new packages of care and support.

The provider did not always detect and control potential risks in the care environment. They did not make sure equipment, facilities and technology supported the delivery of safe care. The provider did not identify, assess and mitigate risks to the environment where care was delivered. There was no systematic approach to risk assessment of care environments and there was no monitoring or review process in place to manage any changes to the environment.

There were sufficient staff to provide care to the single person supported by the provider. However, there was limited assurance the provider could use the existing staff team to deliver care and support to any other people. Pre-employment documentation was not always checked to ensure staff were safe to work with both adults and children. Members of staff worked well together and there was positive feedback about their practice. The provider had supported members of staff to access a range of different training opportunities including the care certificate and training specifically about support people with learning disabilities and autistic people.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. The provider had an infection prevention and control (IPC) policy in place and members of staff confirmed they had access to personal protective equipment (PPE). Members of staff had accessed training about hand hygiene, safe handling of sharps, standard infection precautions and environmental cleaning.

The provider did not make sure medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning. The provider used an electronic planning system for medication management, however, there was no systematic approach to safe management of medications and there was no evidence of reviews or audits of administration of medications. A bespoke medication administration system had been developed for a person the provider supported but this was not supported by an organised and systematic approach to safe management of medications. The provider did not have any medication management policies in place which referenced people with a learning disability or autistic people. There was no reference or understanding of NHS England’s guidance to support stopping over medication of people with a learning disability and autistic people (STOMP) or the national supporting treatment and appropriate medication in paediatrics (STAMP) programme which aims to make sure autistic children and young people and those with a learning disability get medication for the right reason, in the right dose and for as short a time as possible.