The Gables

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• 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

People were still not receiving the standard of care expected. People continued to be not always safe or protected from the risk of harm. There were still 3 breaches of regulations in relation to safe care and treatment, safeguarding and staffing. There was a new breach in relation to premises and equipment. Staff had assessed potential risks to people however they had not ensured there was consistency in the information recorded across people’s risk assessment records. Some risks to people had not been identified or adequately mitigated. There were not fully effective systems, processes and practices to ensure people were protected from the risk of abuse. Staff did not understand the misuse of medication is a form of institutional abuse. Staff did not have a clear understanding of the Deprivation of Liberty Safeguards (DoLS) and applications were not always made appropriately. People did not have a safe environment, designed to meet their needs. There were not effective arrangements in place to monitor the safety and upkeep of the premises. There were not robust processes in place to ensure people’s medicines were always managed safely and in accordance with national guidance. There were not effective approaches in place to identify, assess and manage the risk of infection. Not all aspects of the premises were clean and hygienic. Staff did not all receive the support they needed to enable them to deliver safe care, including an induction, training and supervisions. Incidents had not all been appropriately reported and investigated for people’s safety. Care and support were not always planned in ways that ensured continuity for people between services. However, the interim manager understood the risks to people’s safety and was starting to work with the staff team in order to make the required changes.

This service scored 44 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People did not report having concerns about the learning culture of the service. They told us they felt safe in the care of staff. People who could communicate their needs told us they would raise any issues they had with staff. Relatives told us they had been informed of incidents by staff, such as if their loved one had fallen.

The interim manager said staff noted important information about people which needed to be shared during the shift handovers. Most staff spoken with told us they had been trained in the use of incident forms which they were now expected to complete after any safety events, to enable a review and any required actions to be identified and taken. The deputy manager told us management then reviewed the completed incident forms. However, a staff member was not sure where the incident forms were kept and said they had not been told how to complete them. Not all staff had the required knowledge to ensure they could follow the process in the event of an incident. Staff told us they not aware of having received any feedback from incidents which had occurred. In order to share any areas for learning and improvement in people’s care, following incident reviews. Learning from incidents had not always been shared with staff.

We saw incident forms provided details of the incident, such as if the person had sustained an injury and the actions taken by staff. However incident forms had not always been completed by staff following safety concerns. A person’s records showed they had been admitted to hospital following an incident. However, there was not an incident form as required to document what had happened to them, when and any follow-up actions needed for their on-going safety. The previous registered manager had kept a monthly spreadsheet of incidents in order to identify any trends in relation to the time and place incidents which occurred. However, the spreadsheet did not always reflect the total number of incidents which had occurred. The March 2024 spreadsheet contained 3 incidents but there had been 10 and the April 2024 spreadsheet contained 2 incidents but there were 5. Therefore, the spreadsheets were not a complete record of the total number of incidents which had occurred in the service each month and the monthly analysis was not based on a complete record. It was not clear if any learning from the analysis was to be or had been shared with staff, or when. The provider could not demonstrate all incidents were reported, investigated and analyzed for trends. Therefore, there was a risk people could experience further incidents which could have been mitigated. The systems in place were not robust enough to ensure lessons were learned to continually identify and embed good practices and to meet people’s needs.

Relatives told us they did not have any concerns. They told us either their loved ones had not needed to transition to other services, or where they had, they were satisfied relevant information had been shared as required.

The interim manager told us there was a staff WhatsApp group to share general information amongst staff, whilst information about people and their care was shared via the staff shift handover and an ‘important information’ sheet which staff were expected to read and update themselves. Whilst staff said the information provided in the shift handovers had improved. Some staff said they still found information was not always handed over properly during the handover or they found more detailed information was needed. There was a potential risk information about risks to people to ensure continuity of care when they moved to or from services could be missed. The interim manager told us they were planning to introduce ‘Situation, Background, Assessment, Recommendation’ (SBAR), which is a structured process to facilitate the effective sharing of clinical information externally. This will provide staff with a structured approach for the sharing of clinical information when they contact services. Staff also told us there was not a process in place to ensure relevant information about people, such as whether they were living with dementia and their care and communication needs were shared with services, such as hospitals, when people were admitted. This created a potential risk people who could not advocate for themselves would not receive continuity of care.

Partner agencies told us the provider was working on embedding their new systems and further work was required to ensure they were robust and fully effective. However, they had found the interim manager was already reaching out for support and further training.

We saw care plans did not contain communication protocols or procedures to support hospital admissions as per national guidance. However, staff did have access to the local authorities ‘post-falls’ protocol to inform and guide them about whom to contact externally and when in the event a person experienced a fall.

People told us they felt safe in the care of staff, whom they found to be kind. Relatives overall had no concerns about their loved ones. A relative told us they had been informed by staff of a previous incident involving their loved one, but they had not been told of the follow up action taken. Another relative confirmed the new interim manager had informed them immediately when a safeguarding alert was raised and of the actions taken.

Staff told us they had completed safeguarding training and demonstrated they understood the actions they should take if they had concerns about people. A staff member said they now felt more confident about reporting any safeguarding concerns. Staff said posters providing information about whom to raise concerns with and how, were located throughout the building. However, not all staff spoken with understood the Mental Capacity Act 2005 (MCA) or the Deprivation of Liberty Safeguards (DoLS). Staff told us most people accommodated were subject to DoLS, but they did not know who had restrictions in place upon their movements. Another staff member was unsure about the meaning of either the MCA or DoLS. Therefore, staff were not clear about whom was subject to legal restrictions upon their movements and who was not.

We identified a person was being administered a medication in a manner which breached their human rights. Staff had not identified the practice was abusive until we brought it to their attention. We saw the interim manager immediately took action to safeguard the person once we brought this to their attention. Staff had not understood the misuse of medication is a form of institutional abuse. However, during the course of the site visits we otherwise observed staff interacted with people appropriately.

We saw from the records not all staff had completed either the provider’s online or face to face safeguarding or MCA/ DoLS training. Staff did not all have the required level of knowledge needed in order to ensure people’s human rights were upheld. We also identified 2 people had DoLS applications made by staff to legally authorise the restrictions in place upon them, but their records showed they had the capacity to consent to their care. Therefore, these applications were not required as legal requirements had not been met. This also showed staff had not fully understood when a DoLS was required. They had not ensured applications were only made when people lacked the capacity to consent to their care and any associated restrictions. This combined with not all staff being aware of whom was subject to DoLS, created a potential risk of people being subjected to restrictions upon their movements which they had not consented to. The local authority require all falls to be reported where people’s care is funded by the authority, however, this had not always been done. Safeguarding guidance provided after incidents such as the need for the use of a pressure mat had not always been followed as they could not be used. We saw where staff had completed incident forms and people had sustained an injury, they had not always completed a body map as per good practice guidance. A body map provides a visual record of any injuries. Which can then be used when reviewing incidents and assessing if any non-accidental harm has occurred or if the incident is part of a wider trend. There was a potential risk that without a body map, such information may be missed. However, there was a safeguarding policy and guidance for staff about whom to contact.

Relatives told us they were satisfied overall with how risks to their loved ones were managed. Relatives confirmed they had seen their loved one’s transferred by 2 staff and that staff ensured people had their walking aids. However, a relative expressed concerns about their loved one’s call bell not working, to enable them to request staff’s assistance if required. People and relatives also told us they were not aware of any written information about how risks were to be managed. Although people felt safe, they did not always feel informed about potential risks to them and how they were to be managed.

We requested a written record of how many people were accommodated and their care needs at the start of the first day of the site visits. Staff told us there was not such a record in use and they were not sure if there were 16 or 17 people accommodated. There was not a record of how many people were accommodated in the event the service needed to be evacuated. Staff told us they would rely on information in people’s personal emergency evacuation plans (PEEPs) in the event of an emergency to ensure people received safe care. Staff did not have access to a central record in the event of an emergency. A member of staff told us they were aware where people’s risk assessments were kept but said they had not been directed to read them nor given the time to do so. Staff were not familiar with the International Dysphagia Diet Standardisation Initiative (IDDSI) which provides standardized definitions for the modification of food and liquids in care settings. To ensure people receive modified foods which are consistently as prescribed by the Speech and Language Therapist (SaLT) for their safety. Staff who lacked this knowledge were at risk of giving people foods which were not of a safe consistency for them.

We observed 3 people coughing when eating their lunch, however, 2 of them did not have a choking risk assessment. The risks to them from choking had not been identified by staff or assessed. We observed a person’s whole meal was pureed as one and served to them at lunchtime, which is not in accordance with good practice guidance. Their choking risk assessment showed the risks to them from choking had been identified in January 2024, but staff told us they had only just asked for these risks to be assessed by the (SaLT) therapist. This person had not been referred to the SaLT in a timely manner and staff had modified their food for several months without seeking any external guidance. We saw floor sensor alarm mats were not used to mitigate the risk of people falling out of bed where required. Staff confirmed this was because they could not be plugged into the call bell system and if they were powered by batteries, staff could not hear them if the person’s room was upstairs. Staff told us a person needed a sensor mat at night but said, 'The risk is not managed currently.' The risks of people falling out of bed were not mitigated with the use of sensor mats. We observed call bells were not always in reach of people in their bedrooms, a person was seen tapping their cup on their table to get staff's attention. We had to call for staff for another person as they needed the bathroom but did not have a call bell in sight. However, staff were observed to transfer people safely.

Staff had not fully assessed and mitigated risks to people. A person’s risk assessment noted they were 'at risk' from pressure damage. We saw they were not encouraged by staff to re-position for over 5 hours, until they complained they felt sore. This left them at risk of developing pressure damage. Another person’s records contained conflicting information for staff about how often they should be re-positioned. There was a risk they would not be re-positioned frequently enough to manage the risks of pressure damage. The interim manager had just introduced a monitoring chart, for staff to document when they assisted this person to change position. A person’s risk assessment noted when walking unaided they were at high risk, and they needed a walking stick to walk independently. The person’s bedroom was on the top floor of the home. Staff told us, this person got up regularly at night and came downstairs. They said, “I think [person] knows the risks. However, at night there is a risk with the stairs.” The risks to this person when coming downstairs at night had not been mitigated. A person’s care plan said staff needed to be aware of their whereabouts and their stairs risk assessment showed they were at high risk. However, we frequently observed during the site visits they were alone in the communal areas, no staff were in the vicinity and staff did not have sufficient oversight of their safety. People’s care plans and risk assessments contained conflicting information and had not always been updated. A person’s care records had not been updated to reflect they had moved bedroom, and they were no longer independently mobile. We observed they were hoisted but their care records had not been updated to reflect this change or the equipment required to transfer them safely noted.

A relative told us their loved one's toilet had broken and not been repaired for the past 4 weeks. The interim manager took immediate action to rectify this when we brought it to their attention. However, people and relatives otherwise did not have concerns about the environment. A relative told there had been new lights in the dining room and these had made a positive impact. A person told us they were having new carpets and chairs in the lounge. We saw the new chairs had been purchased and were about to be put into use for people.

Staff told us people had to carry their nurse call alarms with them. However, this meant people had to remember to take the alarm with them when they left their bedroom. Not everyone was able to remember to carry it. A staff member told us they understood how to ensure the environment was kept safe for people, as they had been shown, whist another staff member was unsure. Not all staff were confident about how to ensure a safe environment for people. The interim manager told us about the immediate measures they were taking for people’s safety and the actions which had been taken. These included arrangements to make one of the stairwells safer. They also confirmed they planned to re-decorate the service.

We observed potential risks in the care environment had not all been identified or controlled. The conservatory door used to access the rear garden was not lockable and had a personal alarm taped to it, in order to alert staff if it was opened. This was not a robust way to manage this risk to people. We saw from the rear garden people had access to 3 stairwells located in the rear garden and the rear courtyard which they could potentially access. People could not access the garden independently and freely as staff had to supervise them due to the level of risk to them. The perimeter of the rear garden was not fully secure to ensure no-one either exited or entered the garden. The environment was not well maintained. We saw exposed wiring in one bathroom, and exposed pipes in another and holes in the ceiling. We also saw some equipment was broken, such as a shower hose and a bath control panel. Staff had not always secured storage cupboards where they contained products people could swallow or the boiler which people could touch. Two bathrooms were cluttered with equipment and clothing so people could not access them safely. Some people’s en-suite toilets were a cubicle, with a gap under the sides which was not either soundproof or dignified. The conservatory roof had leaks. However, we saw there was dementia friendly signage to inform and guide people.

We observed potential risks in the care environment had not all been identified or controlled. The conservatory door used to access the rear garden was not lockable and had a personal alarm taped to it, in order to alert staff if it was opened. This was not a robust way to manage this risk to people. We saw from the rear garden people had access to 3 stairwells located in the rear garden and the rear courtyard which they could potentially access. People could not access the garden independently and freely as staff had to supervise them due to the level of risk to them. The perimeter of the rear garden was not fully secure to ensure no-one either exited or entered the garden. The environment was not well maintained. We saw exposed wiring in one bathroom, and exposed pipes in another and holes in the ceiling. We also saw some equipment was broken, such as a shower hose and a bath control panel. Staff had not always secured storage cupboards where they contained products people could swallow or the boiler which people could touch. Two bathrooms were cluttered with equipment and clothing so people could not access them safely. Some people’s en-suite toilets were a cubicle, with a gap under the sides which was not either soundproof or dignified. The conservatory roof had leaks. However, we saw there was dementia friendly signage to inform and guide people.

People and relatives had no concerns overall about the staffing levels provided in the home or the competency of staff. A relative said if their loved one called out staff went straight to them. People liked the staff who cared for them. However, a relative commented, “If anything was to happen, they wouldn’t know as there are no staff in the lounge.”

Staff told us they had not all experienced a proper induction to their role when they commenced work. A staff member said their induction had involved shadowing more experienced staff for one day and then they had been “left to their own devices.” Another staff member said they had experienced a lack of training until the arrival of the interim manager. Staff also said there had been a lack of supervisions and appraisals. The interim manager confirmed they were about to start supervisions with staff. The interim manager told us staff roles had not been properly defined and developed to ensure all staff had a clear understanding of their role and that senior staff were fully empowered and utilized within their role. The interim manager said as staff worked a variety of shifts, it was difficult to evidence if the staffing provided actually reflected people’s staffing needs. However, they had begun working with staff on the rostering system to ensure staff worked the same shift times.

We observed at lunch a staff member stood over a person to support them with their lunch rather than sit to their side, which would have meant they were sat with the person at their eye level. The staff member had not understood the best method to support this person. We saw staff were not always located in the communal areas when vulnerable people who required supervision for their safety were there. We also observed staff assisted a person very quickly with their meal, rather than taking their time supporting the person. However, we also saw staff sitting with people as they assisted them and staff chatting with people as they supported them. It appeared there were sufficient staff rostered for the number of people accommodated at the site visits.

There was no evidence to demonstrate new staff had received an induction to their role. The provider’s recruitment policy required new staff to receive an induction both to their role and the company. Staff were also to be provided with additional support and guidance during the first month of their employment before being included in the schedule for supervisions and annual appraisals. Four staff did not have any records to show any one to one supervisions of their work had taken place. Only 1 staff member had received an annual appraisal of their work, to enable them to reflect upon their performance and identify areas for development. The other 26 staff had not had an appraisal. Staff had not all completed either the provider’s mandatory or additional training, where relevant to their role. There was no evidence staff had completed IDDSI training, but several people were at risk of choking. Staff had not completed this training which left people at risk of not receiving suitable foods for their needs, or foods which had not been modified safely. The provider required staff to complete 9 mandatory training courses where relevant to their role, staff had only completed fire safety and medicines where relevant to their role. Staff recruitment checks had been completed but a staff member's records were not fully robust in demonstrating if all required pre-employment checks had been completed. Staff had not received the support and supervision they required to enable them to understand how to provide safe care to people.

People and relatives did not raise any concerns about the cleanliness of the service.

Staff told us they had not all received training in infection control. Staff were not all clear about what infection control measures were in place. A person was unwell, but staff said they had not been provided with clear guidance about how to care for the person safely.

We observed aspects of the service were unclean. Staff had not completed high level cleaning thoroughly and we saw extractor fans were dirty and covered in cobwebs. Cleaning equipment such as mops and buckets were dirty. The communal bathrooms contained people’s personal toiletries and towels which created a risk of cross-infection. The lino in a toilet was coming away from both sides of the toilet, which made it difficult to clean thoroughly. There was a lack of hand sanitizer for people to clean their hands. We observed staff placed biscuits on the surfaces next to people, rather than using a plate. This risked people eating food which had been in contact with contaminated surfaces. We also saw food was not covered as staff took it from the kitchen to the dining room. People’s food was exposed, which risked contamination as it was carried through to the dining room. However, we did see staff wore aprons and gloves and cleaners were cleaning the service.

The person who was unwell did not have any signage on their bedroom door to inform and guide people not to enter. This created a potential risk of infection to certain groups of people. Staff had not all completed relevant training for their role. Four staff had not completed infection control training and 3 staff had not completed health and safety or hazardous substances training, to ensure they understood how products were to be stored and managed safely. There were not any cleaning schedules in place apart from for the kitchen to guide and inform staff of what to clean, how, and how often. Staff told us their cleaning routine but did not have any written guidance to follow as per national guidance. There was not a record of what had been cleaned, to enable staff’s work to be checked. There was not an infection control lead for the service, as the former lead, the registered manager, had recently left.

Two relatives spoken with expressed concerns about their loved one's medicines. None of the people spoken with, apart from 2 knew what medication they were prescribed or whether a doctor had reviewed their medications. However, other people and relatives did not have concerns about how their medicines were managed.

Staff were unable to describe or show us records held by the service to describe how, when and where creams were to be applied for people or provide detailed records of this care being delivered. However, staff described how they would administer creams when delivering personal care including an entry in the daily record. The interim manager told us, they were about to upgrade people’s medicine records onto an electronic system.

People’s medicines administration records lacked a summary page and information concerning their allergies and information about how they preferred to take their medicines. Not all people’s records contained a recent photograph of them to aid identification. Administration records indicated 4 people may not have received their medicines as prescribed. A person had been administered a medication to be given ‘when required’ consistently over a period of time. Information to support staff administer medicines in people’s care plans, when required and variable dose protocols, lacked sufficient individualized information and was not consistent. A person’s cognition and mood, medication, sleeping care plans and when required protocol lacked sufficient personalized information. We identified a few incomplete records in the controlled drugs (CD) records. Controlled drugs records lacked details of when CD’s were returned to the community pharmacy for destruction. As only current fridge and room temperatures were recorded, we were not assured medicines were stored within their recommended temperature ranges. However, medicines including CD’s and those requiring refrigeration were stored securely. Staff who administered medicines had completed relevant training.