Gabriel Court Limited

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

At the last inspection the provider was in breach of Regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this assessment the provider remains in breach of Regulation 17 and conditions of monthly reports to the Care Quality Commission (CQC) remain on the providers registration. There had been a high turnover of managers in the home. A new manager was in post that would need to listen and build trust with the staff team to ensure a positive culture. Systems and processes were not effective in identifying risks in the environment and actioning improvements. The provider had not maintained effective oversight of risk and People’s needs, people had been exposed to risk of harm. Accidents and incidents had not been managed effectively. Progress on improvement was slow and the provider had been unable to embed and sustain improvements once external support from stakeholders was withdrawn. The provider had commissioned external support with improvements but this had not improved the quality of the service to date. The provider had not adhered to the conditions of their registration placed upon them at the last inspection.

This service scored 32 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We were not reassured that there was always a positive culture in the home or between the staff and management team. There had been a high turnover of managers at the service. However, a new manager was in post who was keen to make improvements and build relationships with staff. This would need to be developed and embedded to build staff confidence and improve the culture in the home. One staff member told us, “We have meetings, loads of things discussed but no action really, things seem to get worse. There was a massive turnover of managers we hoped the new manager would change things but it’s just never happened.” A staff member said that not all staff are committed to care, they said they leave the building early and spend time on their phones instead of engaging with residents, they said, “The residents tell us they are ignored.” One staff member said, the management team did seem to be making changes which had been positive and they were putting money into things. They felt that care staff and team leaders roles could be developed and utilized further to contribute to the improvement of the service. The provider told us that retention of managers had been a challenge, but they were confident in the appointment of the new manager and felt that there would be positive improvements going forward.

The failure to accurately record accidents and incidents and staff witnessing events that they did not believe were recorded or actioned gave us some concern around potential for closed cultures within the service. The provider will need to ensure a more robust system is in place where staff feel that they are listened to and action taken when they raise concerns.

Staff were not assured that management were monitoring all staff were delivering kind and compassionate care or ensuring people had basic items to ensure dignified and safe care. One staff member said. “We have told management that a lot of the residents don’t have shower gel, we are washing them in shampoo or antibac soap as we don’t have anything else, that’s disgusting.” Another staff member said, “We used to have Key workers who checked on things like clothes and toiletries, they would call family members for new clothes or shower gel, the home used to supply shower gel but don’t any more.” The staff member told us they were worried about the affects anti-bacterial soaps and shampoo on skin integrity. A staff member told us that residents were often heavily soiled at shift changeovers, they said staff use night pads consistently to reduce the amount of times continence pads needed to be changed and save time. Most staff told us there wasn’t enough staff to meet people’s needs.

There had been a high turnover of management at the service, the provider had commissioned a consultant to work with the service, however, the quality of the service had been inconsistent with improvements not sustained and embedded in practice. Action plans were in place but they evidence slow progress on improvement and had not identified and actioned issues in a timely manner. A new manager with previous experience was newly in place at the time of the site visit and is in the application process to be the registered manager for the service.

Staff told us they felt confident to speak up with any concern but they did not always feel listened to or see action taken. One staff member said, “I do feel I can speak up and I have done but [they don’t listen].” Another staff member said, “I have raised things, but they don’t listen nothing has been done.” One staff member said, “Not sure about what freedom to speak up is, but I feel confident to speak to managers. I have raised concerns about staff levels.” Another staff member told us they had felt listened to.

We were not assured that the manager had a good understanding of a speak up culture. Managers or a person allocated as speak up guardian ensure that people who speak up are thanked, that the issues they raise are responded to, and make sure that the person speaking up receives feedback on the actions taken. This had not always been the case for staff in this home. The provider had a complaints policy for people that included details outside of the organisation where people could make complaints including the local authority and the local government ombudsman. There was a whistleblowing policy for staff guidance.

Staff told us they did not feel they were always treated fairly, they said there were disparities in pay across roles that did not reflect workload and responsibility equally. There were some concerns that less experienced staff were not identifying issues that more experienced staff were, and they may need further support training to keep people safe and meet their needs. The manager planned to build positive relationships with the staff team. There was evidence the manager had consulted with staff to ensure their personal circumstances and caring responsibilities outside of work were considered when rostering for shifts.

More work was needed to ensure an inclusive culture where staff felt listened to and action was taken to improve the quality and the safety of the service.

Staff shared their concerns with us about staff numbers and how this was affecting the safety and the quality of the service. One staff member told us, “I have made errors when I have been under stain & I worry this will happen again as I am distracted looking after multiple people, I reported this immediately but we don’t have the staff to support.” A person told us they had raised concerns at a residents meeting about staff numbers but was not reassured they would be listened to, they felt that the provider was reluctant to spend money on increasing staffing. We discussed staffing and deployment of staff with the provider who was relying on dependency tools and their own infrequent observations as a means of monitoring staffing numbers. The provider was advised by the commission that they must ensure they meet the conditions of their registration which were imposed upon them at our last inspection to ensure adequate staffing or risk prosecution from the commission. Staffing had been an ongoing issue and was not resolved, therefore the conditions on registration remain. The provider reassured the commission that they had now deployed staff accordingly this would need to be continued and embedded in practice.

Although audits and action plans were in place they had failed to identify some of the concerns found during the assessment. For example concerns around staff numbers and the safety of the environment. Action plans that were in place evidenced slow progress, with some action outstanding for over a year. Provider observations and daily walk arounds had failed to identify that conditions on the providers registration in relation to staffing was not met. Risk assessments and care not implemented in a timely manner on admission and not reviewed and updated as people’s needs changed. The provider implemented a new process post our assessment which meant new admissions would be overseen by a member of the senior management team to ensure staff had all the information needed on admission to keep people safe. These new systems would need to be continued and embedded in practice to ensure sustained improvement.

People’s care and safety needs were not consistently met. The provider had failed to embed an continuously sustain improvements. The support from the local authority following a suspension of placements in 2023 had been successful in initial improvements but these were not sustained once this support was reduced and a temporary suspension was imposed again following our site visit which has since been lifted. A infection control audit conducted by a partner agency in early 2024 found a number of concerns that had not been identified via the providers internal auditing systems. This had left people at risk of infection. The provider invested in improvements to comply when they received the outcome of the audit. However, see Vicky’s notes Health care services such as GP and chiropodist visited the home to support people as and when required.

The provider was aware that there was a need to improve the service by driving, sustaining and embedding improvement. Following our site visit the provider and operations manager told us they had implemented weekly progress meetings with the management team to push for action plan completion. The operations manager advised they would be actively present in the home for 2 days per week to support the manager with oversight of quality and safety.

A partner agency told us that the provider and management team took feedback on board and worked with them to improve. However, once support was withdrawn the difficulty was to sustain and embed improvements. Another partner agency told us there had not always been a positive and professional culture within the home. However, they felt there had been some improvement with the new management team but there was still work to do to ensure people received high quality person centred care.

The provider did not have robust systems in place to sustain and embed improvements in the service.

Staff not consistently feel listened to or that lessons had been learned when things went wrong. Staff felt that the hand held devices provided quick access to peoples records which was helpful but there was still work to do to make sure information was accurate and up to date. Leaders were keen to cooperate with stake holders and started to make improvements post assessment to improve the safety and quality of the service. The local authority placed a suspension on new admissions to the service post our assessment until there was evidence of improvement. The suspension was lifted again once improvements were evidenced a short time later.

The provider and manager audits were not always effective in identifying concerns however a recorded mealtime observation which took place in April had identified a number of issues with people’s mealtime experience, some of which could have been addressed immediately. However, the analysis of the observation did not indicate that immediate action was taken, instead it advised that the management team would look at the meal time experience in May during a planned restructure. This had not been added to the providers rolling action plan to ensure this took place in a timely fashion. The rolling action plan reflected slow progress for example where issues with accuracy of information in peoples care plans, falls assessments and accidents and incidents forms had been identified, some as far back as March 2023 were recorded as still in progress.