All inspections: The Gables Retirement Home

Date of Assessment: 21 July to 29 July 2025. The service is a residential care home providing support to adults, some of whom live with dementia. The service is registered to support up to 35 people. At the time of our inspection, 13 people were living at the service.

This inspection was to follow up on previous enforcement action we took against the provider at our last inspection.

The provider was previously in breach of the legal regulations in relation to good governance. Improvements were found at this assessment and the provider was no longer in breach of regulations.

Some areas within the environment were still in need of updating, including signage to help people navigate around the building. However, a clear refurbishment plan was in place. Accidents and incidents were regularly reviewed and analysed. A lessons learned approach was in development to reduce re-occurrence when things went wrong. Improvements had been made and people’s care plans and risk assessments contained accurate and consistent guidance to support people safely, informed by nationally recognised tools and healthcare professional recommendations. Leaders were proactive in initiating investigations when safeguarding concerns were raised to ensure people’s immediate safety. People received support in line with their assessed needs. Staff were effectively deployed. Medicines were stored, administered and managed safely.

Staff reported improvements in team working, and information was effectively shared internally and externally. Systems were in place to monitor people’s health and wellbeing and people were supported to access relevant healthcare services as required.

Staff provided person centred care and were proactive in responding to people’s requests for support. Staff reported an improved morale within the workforce.

Since our last inspection, a new manager was in post. They had worked with the senior leadership team to address our previous inspection findings. They had impacted positively on the culture within the staff team. At this inspection, systems to oversee risk and quality were organised and effective. The provider, and staff, showed a commitment to continuous learning. Leaders were visible and clear in their roles and responsibilities. The provider worked well with partner agencies.

Date of Assessment: 16 April to 7 May 2025. The service is a residential care home providing support to adults, some of whom live with dementia. The service is registered to support up to 35 people. At the time of our inspection, 17 people were living at the service.

This assessment was carried out in response to information of concern received.

The providers systems and processes to oversee risk and quality of the service were not effective. Oversight of accidents and incidents, falls, medicines and care planning failed to identify risk or drive improvements in these areas. This placed people at risk of harm. Medicines were not safely managed or stored in line with best practice guidance. People’s care plans and risk assessments did not always contain sufficient or accurate information to support them safely.

A poor culture had developed between staff teams and leaders, which impacted on the quality-of-care people had received. Not all staff felt supported, or able to speak up. Staff did not always feel learning was shared within the team. The provider had identified this and had plans in place to improve the culture and promote staff well-being.

Staff were not always deployed effectively, or proactive in meeting people’s needs. Improvements were needed to ensure the provider was working in line with the principles of the Mental Capacity Act (2005).

A maintenance improvement plan was in place to improve the overall environment and facilities. However, people did have access to equipment they needed to keep safe. Staff felt the digital system for sharing information worked well. People’s religious and cultural needs were promoted. A multi-disciplinary team approach was reported to work well in ensuring people’s health and well-being needs were met. Relevant policies and procedures were in place to support people to make complaints. People were supported to make decisions about how they wished to be cared for at the end of their lives. The provider engaged with partners in the adult social care sector.

At our last inspection the provider was in breach of the legal regulation relating to governance. Not enough improvement had been made at this inspection and the provider remained in breach of regulation 17, good governance.

The provider was responsive to feedback about the service and took immediate action to address concerns about safety. Additionally, the provider shared information following this assessment about improvements that were being made.

About the service

The Gables Retirement Home is a residential care home providing accommodation and personal care for up to 35 people. The service provides support to older adults, some of whom are living with dementia. At the time of our inspection there were 23 people using the service. The registered manager explained that the home had 24 bedrooms, some of which could be used to accommodate people who wished to share, at the time of our inspection no one was sharing a room.

People’s experience of using this service and what we found

Although people and their families told us they felt the service was safe we found several issues related to the safety. People were not consistently protected from risk as care plans and risk assessments were not always in place. Medicines were not always managed or stored safely. Issues with the cleanliness of the environment and equipment increased the risk of infection spreading. Systems were in place to protect people from the risk of abuse. The provider had taken opportunities to learn from incidents and improve care.

There were enough staff to keep people safe, but people’s families told us variations in staffing levels impacted upon the provision of person-centred care. We received variable feedback about the approach of staff and people’s right to privacy was not always upheld. Most people had adequate care plans in place, however some people’s needs were not always assessed in a timely manner and consequently staff were not consistently provided with adequate information to support people.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice, however, some further work was needed with recording in this area.

People were supported with their physical and mental health and referrals were made to external health professionals when required. People had enough to eat and drink and people’s dietary needs were met.

People were supported to maintain relationships with those who were important to them and there were a range of activities for people to take part in at the home. People received person centred, compassionate care at the end of their lives. People’s complaints were responded to swiftly and to their satisfaction.

Systems to ensure the quality and safety of the service were not always fully effective. There had been issues with the culture of the home which impacted upon care. Communication with people’s families was not always effective. The provider was passionate about providing high quality care, they were open to feedback and responsive to issues identified during our inspection. Feedback from people, families and staff was used to improve the quality of the service.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

This service was registered with us on 1 August 2019 and this is the first inspection. The last rating for the service under the previous provider was good, published on 24 June 2017.

Why we inspected

The inspection was prompted in part due to concerns received about the conduct of staff. A decision was made for us to inspect and examine those risks.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We have identified a breach in relation to governance at this inspection. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

The Gables Retirement Home

All Inspections

During an assessment under our new approach

During an assessment under our new approach

30 May 2022

During a routine inspection