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 staffing.

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 finding person centred solutions 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 they were 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 people’s safety effectively. Risk and care records were not always accurate so would not ensure continuity of care, when people moved between different services. Care plans and risk assessments were found to either not be in place for staff guidance or contained inconsistent information on how to keep people safe and meet their care needs. For example, one person’s file included a falls risk assessment and a moving and handling risk assessment completed on the same date with contradictory information stating, the person could use a walking frame to go to the toilet, could walk unaided and was nursed in bed. The person told us, “I am always nursed in bed”. We visited one person in their home and found there were no risk assessments or care plans in place for staff guidance or information sharing for emergency services should the person require an emergency admission. This meant there was a risk of people receiving unsafe care or care that did not meet their needs.

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 Care Quality Commission [CQC].

The provider had failed to act and work with the local authority and Integrated Care Board [ICB] to improve people’s safety following a suspension of any new placements due to quality and safeguarding concerns. [A suspension meant that the local authority or ICB would not place any new people with the service until improvements were made]. 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 they were not always safe from harm, as staff did not have the information needed to ensure people were safe. However, people told us they felt safe with staff who were kind and caring, we observed people to be relaxed and comfortable around staff and staff were trained in safeguarding adults. A relative told us, “The staff are very kind, we get on well with them all.” A person also spoke positively of their staff member and their professional relationship.

The provider did not work well with people to understand and manage risks. Staff did not have clear guidance to provide care to meet people’s needs that was safe, supportive and enabled people to do that mattered to them. Risk assessments and care plans were either not available in people’s homes or contained conflicting or incorrect information. A relative told us, “There aren’t any risk assessments or care plans but they [staff] write care notes and there are medicine charts”. Where people were using a Percutaneous Endoscopic Gastrostomy [PEG] for their food and fluid intake, records contained conflicting information for staff. For example, one person’s nutrition care plan made no reference to the PEG or that the person was nil by mouth it stated, “Ensure [person] is eating a varied and balanced diet”. For a second person with a PEG we found the risk assessment in relation to nutrition had been marked as, “No” for the question of if the person had a PEG, staff were guided to encourage fluids with no mention of nil by mouth, their nutrition care plan made no reference to the PEG or that the person was nil by mouth it stated, “Ensure [person] is eating a varied and balanced diet. A care interventions record includes “[Person] should be offered 3 meals daily including at least 2 cooked meals along with a range of drinks and snacks. Both people had a general care plan that included guidance on the PEG so it’s unclear why the other records did not mirror this. There was a risk staff could be confused, resulting in people receiving food and drinks that increased the risk of choking. People at risk of constipation were not supported safely as care plans did not include what was the normal bowel patterns for people or what action to take if people had not opened their bowels for a number of days. We found 1 person had not opened their bowels for 5 days this coincided with 3 days of missed constipation medicine for this person. There was no evidence of GP advice sought.

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 deployed to 2 different people at the same time. There was no system in place to ensure and monitor that staff had arrived at people’s homes or at the allocated time and stayed for the commissioned time, this meant people were at an increased risk of missed calls.

One person was at risk of pressure sores and had a pressure relieving air mattress, there was no guidance at the persons home for staff on what the mattress should be set at as per the persons weight and there was no record for staff to complete regular checks of the mattress to ensure it was in working order. The same person was using bed rails, there was no evidence of a risk assessment at the persons home for staff guidance or any safety checks. Another person had a bed rails risk assessment in place but we observed there were no bed rails on the persons bed, the person told us “I haven’t had bed rails for about a year”. We were not assured that equipment checks were always taking place or that information for staff about equipment was reliable.

The provider did not make sure staff were recruited safely and in line with regulatory requirement. 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 a enhanced disclosure and barring service check [DBS] risk assessments had not been completed to cover this time frame to ensure peoples 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 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. A relative told us that staff were good with their relative and knew how to look after them, however, we found no evidence that staff had identified and highlighted risks to the person or carried out basic safety checks for equipment, there was also evidence of medication errors. We were not assured that staff were consistently recruited safely, were competent or received effective support to ensure people’s needs were met.

The provider did not always assess or manage the risk of infection and ensure early detection and action could be taken by staff. One person had a catheter in situ that was managed by staff however there was no risk assessment or care plan in the persons home for staff guidance in terms of cleaning the site and monitoring the site for infection. Although staff were recording in daily care notes the urine output for the catheter, there was no system in place for calculating the total output, identifying the risk of retention or blockage or how often and who would change any catheter bags. This increased the risk of infection and did not support early detection of infection. Staff had received training in infection prevention and control and food hygiene and personal protective equipment [PPE] was available for staff use in people’s homes.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. A relative told us that staff administered all the medicines as prescribed. However, we found several concerns for safety of medicines. As and when required medicines [PRN] and homely remedies did not always have protocols in place for staff guidance, for 1 person we found this to be the case for 7 of their medicines. Not all prescribed medication was recorded on MAR charts. For example, they had 3 prescribed medications not recorded, one of which was transdermal patches which also did not have associated body maps in place to ensure effective rotation and removal of old patches prior to re administering, this meant there was an increased risk of skin irritation and overdose. We found errors in transcribing prescriptions to medication administration records [MAR] and a lack of detail for staff guidance including a dosage error for 1 medicine and a note on another medicine stating to be taken before food instead of as prescribed which was, 30-60 mins before food. There were also a number of missed medications with no reason recorded or evidence of advice sought. We found medicine concerns for a further 3 people including, a PRN was in place for a medicine which did not include the maximum dose or minimum time between doses for staff guidance and to prevent medication overdose, no PRNs for homely remedies, missed medications, errors in transcribing onto MAR charts, allergies not recorded, medicine counts not completed to identify if any medicines were missed. During a visit to 1 persons home the inspector had to intervene to prevent a medication overdose. We were not reassured that the provider or staff were managing medicines safely.