Archived: The 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 good. At this assessment the rating has changed to inadequate. This meant people were not safe and were not protected from avoidable harm.

The service was in breach of legal regulations in relation to safeguarding people, providing safe care and treatment, safe staffing levels, safe recruitment processes, how people were not supported in a person-centred way and in relation to the governance of the service.

This service scored 28 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People’s relatives seemed to suggest there was an open dialogue of communication with the manager and staff, though they were not always as responsive as they could be. Staff were knowledgeable about how to report accidents and incidents, though we found an incident where process had not been followed.

Feedback from partners was not always positive, though some partners felt they were made aware of relevant safety events at the service this was not consistent, one professional said “Sometimes they call and say someone needs to be seen as priority and then we get there and it is not a priority at all and we could have better used our time to see someone that was more urgent.” Another professional told us how they had witnessed unsafe moving and handling practices in the home, a number of months ago, due to a broken hoist. We were able to review some examples of lessons learned which took place following incidents. However, due to a concern we identified and raised, regarding a person’s injury, we did not find the service had a proactive and positive culture of safety based on openness and honesty.

People felt the staff team work well together to ensure they received the care and support they needed, but they were not always kept updated. One person told us, “I think she has had a couple of falls, they let me know. They got the doctor out to check on her. They rang me last week to say she was in hospital as she wasn’t responding, she came around in the hospital, they couldn’t find anything, and they checked her pacemaker. The hospital told them to get the doctor out the next day. I haven’t heard anything yet, but I am going to see her tomorrow.”

Staff spoke about how they get to know new admissions, one staff member said “The manager tells us about admissions. We have handovers to discuss it.” Professionals provided some mixed feedback about whether referrals were made in a timely way. Our findings also supported these concerns as detailed throughout this report, we find referrals were not always being appropriately masde. A communication book was in place, though handover records on the system confirmed that staff did not consistently read the handover notes. We were able to see some examples where appropriate referrals had been made, however this was not consistent.

On arrival, guests (including inspectors) were allowed access through a locked door at the front. We were asked for our ID and were asked to sign into the home to make sure the home had a record of any visitors, which helped keep people safe. However, the signing in book was not in a secure part of the home. We also found that access to the home could be gained through another entrance that was not secure and this posed a risk to people’s safety. Some safeguarding’s were being made based on the accident and incident log we reviewed, though based on our observations we were not assured people were actually safe. We identified issues that amounted to abuse or neglect and these issues had not been identified by the manager.

The service had a safeguarding policy in their paper file that had out of date information in, as it referred to a registered manager and safeguarding lead that were no longer working at the service and although it referenced the relevant local authority it contained no contact information. An updated version was later provided electronically. Deprivation of liberty safeguards (DoLS) were not always being followed, and we were not assured that necessary DoLS referrals were always in place when needed. Following our inspection, we raised an organisational safeguarding due to our concerns.

Staff were able to tell us how they would escalate any potential safeguarding concerns. A Mental Capacity and Deprivation of Liberty Policy and Procedure was in place. The manager confirmed people had access to advocates if they needed this support. People told us they felt safe. One person said, “I have a roof over my head, and I feel safe.” While the people we spoke with expressed they felt safe, our assessment found the elements of safety did not meet the expected standards.

Necessary risks assessments were not always being followed or were not in place. For example, risk assessments were not always in place for health conditions such as diabetes, COPD or epilepsy. One person’s call bell risk assessment was not being followed. Environmental risk assessments were in place though these did not consider all environmental risks or identify some of the risks we found. We found personal emergency evacuation plan (PEEPs) records were in place though these records were not always up to date as we found a PEEP for a person who was no longer at the home. PEEPs were also not fully reflective of the equipment people may require to be safely moved.

People and their relatives felt risks were being managed. One relative told us, “She has to be hoisted in and out of bed, I haven’t seen them do it. I think she has a pressure mat by her bed in case she falls out.” Staff spoke about how they manage various risks and support people with their healthcare needs. While the people and staff we spoke with expressed they felt risks were managed, our assessment found elements of risk management did not meet the expected standards.

The environment was not always safe, this was partly due to fire safety concerns. There was also unsafe access through a lounge door to the outside, inappropriate risk management, very hot water in a bathroom and a very hot water tank that was accessible to all, which posed a risk of scolding.

Fire safety was not being effectively managed. The home did not always have enough staff on duty to safely evacuate people in a timely manner. Concerns relating to doors and windows on an unoccupied floor which did not meet fire safety standards was raised last year by a fire officer and had still not been addressed. Emergency lighting was not in place in all areas of the home that required this. We raised our concerns to the fire officer who visited the home to offer support.

Staff provided mixed feedback on the safety of the environment, this was due to staffing level concerns.

Some improvements could be made to make the environment more dementia friendly as the home supported a high number of people living with dementia. Improvements such as making peoples doors more recognisable and adding contrasting toilet seats could benefit some of the people living at the service.

Some safety certificates were slightly out of date, but these were booked in by the end of the inspection. Generally, people and their relatives felt their loved one was in a safe environment, though one relative said, “When I went once, I saw a resident outside and the staff didn’t know he was there and they rushed to get him, but that was a while ago.” However, our assessment found elements of the environment were not safe.

Safe staffing was not in place. We observed staffing in the home was not appropriate and we were not assured that people were always safe because of this. The was no dependency tool in place to support safe staffing levels. We queried with the manager how staffing levels were able to keep people safe when a staff member took their breaks and we were told that staff breaks are paid, therefore staff could not leave the premises, but on review of staff records we found this not to be the case.

People felt supported by staff, but feedback on staffing levels was mixed. Staff feedback on staffing levels was mixed. One staff member told us, “We do sometimes have to leave the floor unattended. The workload is manageable but for the times when we need to take someone who needs 2 staff, we could do with an extra person.”

The providers policy relating to staff supervisions indicated staff should receive six supervisions a year, however most staff had four. The manager had just completed staff’s annual appraisals. We also found that prior to the new manager starting the admin assistant who had no background in care or a management role was completing staff supervisions.

Safe recruitment practices were not followed. For example, health questionnaires were not in place, gaps in employment were not always addressed and a formal interview process was not recorded.

Staff told us they completed an induction when they started and that they felt they had the appropriate training for their role. Records indicated that staff training was largely up to date.

Safe infection prevention control practices were not always being followed. Communal toiletries, a hairbrush and a toothbrush were found in communal spaces with no labels or names on. One person soiled themselves whilst we were sat in a communal space, we asked staff to assist, which they promptly did, but the chair was not cleaned following the incident.

Records indicated that the home was regularly being cleaned. Cleaning records were in place, signed and up to date, though some areas of the home had a strong smell of urine. People felt the home was clean. One person said, Yes (I think the home is clean), they keep my room clean.” Staff felt the home was clean and tidy. Appropriate Personal Protective Equipment (PPE) was in place

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

Some people were not given their medicines safely because staff failed to follow the prescribers’ and manufacturers’ directions properly. Other people could not have their medicines as prescribed because there was no stock available in the home. One person was unable to have their inhaler for 10 days because it had not been ordered in a timely manner and 2 people were unable to have their prescribed nutritional food supplements for up to 10 days. This put people’s health at risk of harm.

When people were prescribed medicines to be taken ‘when required’ (PRN) or with a choice of dose, the protocols to support their administration were not detailed enough to ensure they were administered safely and consistently.

The records about how much medicine was in the home for people were not always accurate which meant the records could not always show that medicines could all be accounted for or had been administered to people as prescribed.

Staff were not always able to identify individual medicines before they administered them because the system in place to identify medicines was not robust placing people’s health at risk of harm.

There were some medicines, eye drops, creams and test strips in the home which were out of date. This meant that the medicines or test strips may not work properly and if eye drops and creams are out of date, they may cause an infection.

Medicnes were not always stored safely, the fridge temperature was not accurately monitored and on the day of inspection the temperature in the medicine’s cupboard exceeded the recommended temperature for the safe storage of medicines. Creams were stored in people’s bedrooms without any assessments to show it was safe to do so. Waste medicines were stored unsafely in a public area of the home which was against current national guidance for the safe storage of unwanted medicines.

Staff who administered medicines had all received training but only one member of staff had been assessed as competent to administer medicines safely.

We found no evidence that people were harmed at the time of the assessment because the harm is not always immediate. However, people were placed at increased risk of harm by not managing medicines safely.

People did not always know what medication they were prescribed but people found they got their medication when needed, though we found this was not always the case. While the people we spoke with felt medicines were safely managed, we found medicines management did not meet the expected standards.