Gable Healthcare Services Ltd

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 at risk of avoidable harm.

The service was in breach of legal regulation in relation to people’s safe care and treatment and safe recruitment.

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.

The provider did not have a proactive and positive culture of safety based on and mitigating risk of future incidents. They did not always listen to concerns about safety or fully investigate safety events appropriately. Lessons were not learnt to continually identify and embed good practice. Incidents were not always fully recorded. Where incidents were recorded, the content indicated a blame on the person involved and did not support person centred solutions to prevent risk of future incidents. We found incident reports to contain duplicate generic information for lessons learned with no clear individual detail of what action would be taken, by whom or by when to ensure people were better supported.

The provider did not manage or monitor the persons safety effectively. Risk and care records were not always accurate; they would not support or ensure continuity of care, when the person moved between different services. The persons care records were found to contain inconsistent information on how to keep them safe and meet their care needs. For example, the person had conflicting and incorrect information across risk assessments about maintaining their own safety unsupervised by staff, how long they could spend time alone for and how they would contact staff for help if needed. This meant healthcare professionals at other services such as ambulance or hospital would not have clear information to mitigate risk to the person and meet their needs, this increased the risk of harm.

The provider had not worked well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from avoidable harm and neglect. The provider did not share information quickly and appropriately with healthcare partners or the Care Quality Commission [CQC].

External stakeholders had expressed concerns about the safety of the service and related safeguarding concerns. The provider had failed to take sufficient action in relation to these stakeholder concerns. The provider had failed to consistently provide information to CQC regarding safeguarding concerns when it was requested and within deadlines. We found the lack of care records and the level of incorrect or conflicting information within people’s records meant people were not always safe from harm, as staff did not have the information they needed to ensure people were safe. However, staff were trained in safeguarding adults. A person told us they liked their staff and they got on well together.

The provider did not work well with the person to understand and manage risks. Staff did not have clear guidance to ensure they provided care to meet the persons needs that was safe, supportive and enabled person to do the things that mattered to them. Risk assessments and associated care plans contained conflicting or incorrect information. For example, staff were able to tell us that the person had a specific health risk. This information was not recorded in the person’s care plan. This increased risk if the person needed to be supported by unfamiliar staff or was transferred to another service in an emergency, such as a hospital admission. We also identified that staff did not have clear guidance on how to help a person evacuate in an emergency. This is because the evacuation guidance did not reflect the environment the person lived in or their mobility needs. This increased the risk of a delay in emergency evacuation for the person where staff or services that weren’t familiar with the person or the environment, such as fire crew in the case of a fire.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care. The provider had not implemented an effective rota system to ensure staff were effectively deployed, there was some limited data available which was unreliable as showed staff had previously been deployed to 2 different people at the same time. There was no system in place to ensure and monitor that staff had arrived at the persons home or at the allocated time and stayed for the commissioned time, this meant the person was at an increased risk of missed calls. The person’s equipment checks were not always completed as scheduled to ensure moving and handling equipment remained safe and fit for purpose. Where a risk in the environment had been identified this had not been explored to ensure risks were mitigated and prevent harm to the person.

The provider did not make sure staff were recruited safely and in line with regulatory requirements. They did not always make sure staff received effective support, supervision and development. We identified gaps of up to 6 months between staff start dates and evidence of an enhanced disclosure and barring service check [DBS]; risk assessments had not been completed to cover this time frame to ensure people’s safety while checks were completed. Full work history of staff and gaps in their employment had not been explored as per the regulatory requirement and the providers policy and procedure. This meant people were at risk of support from staff that may not be suitable for working with vulnerable people. However, we found no evidence this had impacted on people. Where one staff member had declared an injury there was no risk assessment and we found they were deployed to assist people with high mobility support needs, therefore, we were not reassured health declarations were appropriately screened to ensure any potential risks to staff and people were mitigated. Where a spot check had identified a further training need for a staff member to support a specific person, the person’s name or location was not included to allow for follow up and improvement monitoring. There was also no evidence of extra staff support or training provided for this staff member. The supervision matrix did not evidence that all staff received regular supervision as per the providers policy and procedure. We were not assured that staff were consistently recruited safely, were competent or received effective support to ensure people’s needs were met. There were enough staff deployed to meet the person’s needs. The person had a regular team of staff that knew them well, staff told us they would provide a thorough handover to emergency services where required. However, we found risk assessments and care plans were not accurate. So this could impact the ability of staff to handover information to other professionals.

The provider did not always assess or manage the risk of infection. The persons environmental risk assessment had identified a risk, but the assessment had not explored or put measures in place to mitigate the risk of any potential infection. The persons specific personal care needs were not recorded in their care records therefore any increased infection risk had not been explored and mitigated. Staff had received training in infection prevention and control and food hygiene and personal protective equipment [PPE] was available for staff use in the persons home.

The provider did not make sure that medicines and treatments were safe and met the person’s needs. We found an error in transcribing a prescription to a medication administration records [MAR]. There was a risk staff would not know when to administer this medication and increased the risk of staff inappropriately administering the medication or not administering the medication when required. Medicine records completed and checked by the same staff member which meant errors in transcribing were not checked and identified. Medicine counts had not consistently been completed to identify if any medicines were missed. We were not reassured that the provider or staff were managing medicines safely.