This unannounced inspection took place on the 22 and 23 November 2016. At the last inspection on 3 June 2015, the service was found to be requires improvement under the responsive and well led domains. At this inspection we found there had been some improvement.

The Gables is a care home which provides accommodation with personal care for up to 24 older people. At the time of our inspection 24 people were living at the home.

The provider is also the registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

There were audit systems in place to monitor the quality of the care people received, however they were not always effective at identifying some of the issues we had raised with the registered manager and required some improvement.

People and relatives told us they felt the home was a safe environment for people to live in. Staff spoken with could confidently identify the different types of abuse and explained how they would report abuse. People were protected from the risk of harm and abuse because staff knew what to do and were effectively supported by the provider’s policies and processes. Risks to people were being monitored and staff identified risks to people and explained how those risks should be managed. Staff had a good understanding of the risks and the action that was required. The plans and risk assessments were reviewed and updated on a monthly basis and/or when people's needs changed.

Most of those spoken with felt there was a requirement to increase care staff levels. We saw all staff were busy but were available to provide support to people when needed. This included support for people to eat, drink and move around the home safely. Requests for assistance from people were responded to promptly. The provider’s recruitment processes ensured suitable staff were recruited.

People received appropriate support to take their prescribed medicines and senior care staff maintained accurate records of the medicine they administered to people. Medicines were stored securely and consistently at the recommended temperature given by the manufacturer and were safely disposed of when no longer required.

People were supported by suitably trained staff that told us they received training and support which provided them with the knowledge and skills they needed to do their job effectively. People and relatives felt staff were knowledgeable on how to support people effectively and that staff possessed the necessary skills.

We found mental capacity assessments had been completed for people who lacked the mental capacity to consent to their care and welfare. The provider had taken suitable action when they had identified people who did not have capacity to consent to their care or treatment. Applications had been made to authorise restrictions on people's liberty in their best interests.

People were able to choose what they ate and drank and were supported to maintain a healthy diet with input from dietary specialists. People were supported to receive care and support from a variety of healthcare professionals and received appropriate treatment if they were unwell.

People's care records contained information relating to their specific needs and there was evidence that the care plans were updated when people's needs changed. People and relatives told us they were involved in developing and reviewing their care plans. People were supported by caring and kind staff who demonstrated a positive regard for the people they were supporting. Staff understood how to seek consent from people and how to involve people in their care. We saw staff interacting with people in a friendly and respectful way and that staff respec

The inspection took place on 3 June 2015 and was unannounced. At our last inspection in March 2015 we found there was a breach of Regulation 9 Health and Social Care Act (Regulated Activities) Regulations 2010. During this inspection we saw that changes had been made and the provider was now meeting the requirements of this regulation.

The provider had made improvements to the service including creating new care plans and identifying people’s individual needs and preferences.

The Gables provides accommodation with personal care for up to 24 people, including people with dementia. At the time of our inspection there were 24 people living in the home. The Nominated Individual of the provider was going through the process of becoming the registered manager for the service. There was previously no registered manager for the service at our last inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People were kept safe in the home by staff who had a good understanding of safeguarding and the different types of abuse. The staff we spoke with all knew how to report any concerns and were confident in doing this to make sure people were safe. There were risk assessments for people which identified the different risks associated with their care and conditions.

There were enough staff to meet the needs of people using the service. The manager had reviewed the staffing levels based on the identified needs of people and recruited new staff to meet these needs. Staff were recruited using safe recruitment processes and had all completed criminal records checks and provided application forms with employment history and details of their skills and experience.

People’s medicines were managed safely by staff who had a good understanding of the medicines procedure and were skilled in managing people’s medicines. We saw that medicines were recorded properly and were handled using the correct procedure by staff.

People were supported by staff who were well trained and supported in their work, staff were up to date with their training and received monthly supervision for either the manager or the deputy manager. Staff sought people’s consent for their care and the service operated in accordance with the legal requirements to protect people’s freedom.

People were supported to eat and drink the amount they needed and had the appropriate diet provided for them. People were given choices of meals based on the day’s menu and could request alternatives if they did not like the choices. People with specific dietary needs received these, including people who needed thickened and fortified food or people with diabetes on a low sugar diet.

Staff were caring and we saw many positive interactions between staff and people Staff supported people to make decisions about their care and asked people what they wanted and how they wanted to be supported. Staff respected people’s privacy and dignity, and we saw examples of staff supporting people discreetly when they required personal care.

People had care plans which included information about their life history and preferences. However, the risk assessments and plans were not always personalised to their individual needs. We saw examples of generic risk assessments which were the same in different people’s care files rather than being tailored to each individual person. The provider had identified this problem and had created a new style of risk assessment which was being implemented but was not yet complete.

The provider had a complaints procedure in place which was available in the communal areas and provided to people when moving into the home. People and relatives were able to make complaints and put forward their suggestions for improvements and changes to the home.

Staff told us they were happy working at the service and that it had improved recently. The manager had implemented many changes to the service which had had a positive impact on the home. There were systems in place to monitor falls and take action based on patterns identified through the analysis of the monitoring.

We visited the service in response to concerns that had been raised with us in regards to staffing levels and people having enough to eat and drink to meet their needs. We were told that people’s care needs were not being met because there were not enough staff on duty to assist people. We were told that there was insufficient food available to meet people’s dietary needs.

During our visit we spoke with three staff, the cook, one visiting professional, two relatives, the provider and four people who lived there. We asked people who lived there about their experiences of the service to enable us to identify if the service met their needs.

We asked if the service was effective

People spoken with told us that they were happy with their care. Relatives and our observation told us that some improvements were required in how the home was run. Risks assessments in place to minimise identified risks were not being used effectively to reduce the risks to people’s health. For example, people were not adequately supervised.

We looked at food stocks within the home and we saw that there were limited stocks of some food, for example sugar. The provider and deputy manager confirmed that there was a delivery due that day. A staff member told us the home often ran low on things and it would be better if they had better stocks which were topped up regularly.

We saw that the provisions for maintaining food at safe temperatures was not sufficient. There was a risk that frozen food was not stored safely. The date foods were frozen and to be used by were not clear so there was not an effective stock rotation system so that food was safe to eat.

We carried out this inspection in response to some anonymous concerns about the care and welfare of people who lived at the home. Concerns also included inadequate management arrangements at the home, insufficient numbers of staff on duty and a lack of suitable training and support for staff. We had referred one of the concerns which we considered to be safeguarding issue to the local authority, who investigated and found no evidence to support the allegations.

On the day of our inspection 24 people lived at the home. This included one person who was at the home for respite, this meant that they were at the home for a short stay which could be to give their family a break from their caring responsibilities. We spoke with six people who lived at the home. Some people were unable to verbally share with us their views about their care. We used different ways to evidence their experiences such as observing care and looking at care records. We spoke with four relatives. We also spoke with four members of staff, the newly appointed manager and the registered provider of the home.

Care was planned and delivered to ensure people's safety and welfare. One person told us, “I am very happy here".

Staffing levels were adequate to support people. One person said, "There is enough staff, I don't have to wait long".

People were cared for by staff who were trained to deliver care to an appropriate standard. A relative commented, "I am amazed by how staff have cared for them".

On the day of our inspection there were twenty three people living at the home. We spoke with seven people, six members of staff, the manager and the registered provider. We spoke with three visitors to the home and looked at the care records of three people.

Some people were unable to verbally share with us their views about their care. We used different ways to evidence their experiences such as observing care and speaking with relatives. We spoke with four relatives and a family friend.

Care was planned and delivered to ensure people's safety and welfare. One person told us, “I get the help that I need from staff, I have seen the doctor and dentist for my health".

Safeguarding procedures were in place so that staff would recognise and report any allegations of abuse so that people were protected from the risk of harm.

People who use the service, staff and visitors were protected against the risks of unsafe or unsuitable premises.

Staffing levels were adequate to support people. One person said, "I have my call button and if I need any help staff come quickly".

People were cared for by staff who were trained to deliver care to an appropriate standard.

Systems were in place to identify, assess and manage risks to the health, safety and welfare of people who use the service and others.

People's care records contained relevant information about people's health and wellbeing to ensure that people were not at risk of inappropriate or unsafe care.

We inspected The Gables residential home to check if improvements had been made in the way that the provider assessed and monitored the quality of service provision. At our last inspection in September 2012 we had concerns in relation to the care delivered at the home. We issued a warning notice for regulation 10, as we found that systems were not in place to monitor the quality of service that people received and ensure that the provider identified, monitored and managed risks. We judged at the time that this had a moderate impact on people living at the home.

During this inspection we spoke with the provider, the registered manager and three members of staff. We spoke with a relative and five people living at the home, we also sampled two sets of care records.

We saw that improvements had been made in the provider's quality assurance systems which meant that the risks to people had been reduced. Areas of improvements included how people's views were considered in the delivery of service, a more accessible complaints procedure and the implementation of a more robust auditing system.

We saw that further improvements were still required to ensure that findings from quality assurance systems were effectively analysed so that ongoing learning could take place. This would mean that any themes and trends were easily identified and ensure that improvements made were sustainable.

We heard from the provider of their commitment to improve and maintain standards of care.

We inspected The Gables residential home to check if improvements had been since our last inspection in November 2011. At our last inspection we had concerns in relation to the care delivered at the home and we issued compliance actions.

During this inspection we spoke with five people who lived at the home and observed two people using SOFI. We identified four people to pathway track, this involved following through people’s experience of care, we focused on areas of previous concerns. We also spoke with three members of staff, the registered manager and a relative.

On the day of our inspection there were a total of twenty two people living at the home one of whom was in hospital.

We saw that people were not involved in any meaningful activities and people who were unable to verbally communicate had little staff interaction. Care plans and assessments remained inadequate and were not reviewed to show people's current care needs.

Improvements had been made in infection prevention and control procedures.

The safety and suitability of premises did not promote wellbeing.

Staffing levels were inadequate to meet the needs of people in a timely manner and staff did not have appropriate training to meet the needs of all the people that they cared for.

Systems were not in place to monitor the quality of service that people received and identify, monitor and manage risks.

Records did not reflect people's needs and were not stored securely.

Two people spoke positively about the service they received at The Gables:

“It’s fine”; “I’m happy here”. Another person was less satisfied: “I wouldn't say it’s 100%."

One person told us that she had been living at The Gables for some time. She told us that she enjoyed the food and that the meal that day was “very nice”

Some people did not express a view about their care, but we observed that people with dementia and people with physical frailties did not receive enough attention to ensure their wellbeing.

The inspection took place on 11, 12 and 13 March 2015. Our visit was unannounced on 11 March 2015 and we told the director we would return on 12 March 2015. We returned unannounced on 13 March 2015. The last comprehensive inspection carried was on 31 July and 1 August 2014. We found breaches in the regulations inspected. We commenced enforcement action. A responsive inspection took place on 7 October 2014 following further concerns raised to us. We found that the provider was not meeting the requirements of the regulations inspected and continued enforcement action against the directors of the home.

The home is registered to provide accommodation and personal care for up to 24 people. On the day of our visits we were told there were 19 people living at the home.

The director registered the home with us in 2011. There has been no registered manager in post since August 2013. However, a number of acting managers have been in post. The owner director of the home told us that they now intended to manage the home on a day to day basis.

Although people told us that they felt safe in this home, there were risks to people that had not been identified and actions had not been put into place to reduce the risk of harm or injury to people. This impacted on the safety of people at the home. During our visit we saw one person was not given soft textured food which we saw their hospital discharge information stated they required. During our inspection visit, the person choked on sandwiches given to them by staff. 

Some people told us that they believed they received their medicines as prescribed but other people were not able to tell us about this due to their dementia. We found that suitable arrangements were not in place to ensure that people consistently received their prescribed medicines safely.

Although people told us that staff were caring and kind to them, we saw that staff did not always deliver care to people well. Although staff told us that they received some training, we saw that staff did not always have the skills and knowledge they needed to care and support people safely and effectively.

People and their relatives told us they knew how to make a complaint. Some people and their relatives told us that they felt their complaints were not resolved.

The systems used to assess the quality of the service had not identified the issues that we found during the inspection. This meant the quality monitoring processes were not effective as they had not ensured that people received safe care that met their needs.

We found a breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 in relation to risks to people and actions not always put in place to reduce the risk of harm or injury. You can see what action we told the provider to take at the back of the full version of this report.