Abbeywood House

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

The key question of safe was rated requires improvement at our last inspection. At this assessment some improvements had been made and the provider was no longer in breach of Regulation 13 relating to safeguarding. Staff knew people well and understood their responsibilities around how to keep people safe and where restrictions had been placed on people’s liberty to keep them safe, the provider worked with the local authority to ensure this was lawful and any conditions were being met. However, we found continued breaches in Regulation 12 relating to Safe care and treatment. The provider had failed to ensure risks relating to the management of people’s complex needs and medicines were effectively mitigated and managed. The key question of safe remains requires improvement.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

People told us they felt safe living at the service and did not raise any concerns relating to their safety or well-being. Relatives told us they visited regularly, and there were no restrictions on visiting their loved ones.

Staff we spoke with told us they had received training in safeguarding adults. Staff demonstrated awareness of how and when to escalate safeguarding concerns. Staff were aware of additional agencies they could contact to raise safeguarding concerns, for example, the local authority or CQC. Whilst staff understood safeguarding procedures, none of the staff we spoke with were able to clearly evidence an understanding of the Deprivation of Liberty Safeguards. We spoke to the manager about this, who was arranging more in-depth training and raising this topic in morning meetings and supervision to ensure the staff had a clear understanding.

We observed staff enabling people to walk freely in the lounge and access the community. We witnessed one person wanting to go out for a walk and the service was able to provide a member of staff to support this person.

There was evidence the service had acted on incidents reported to the local safeguarding team. The service had recently identified there was a need to submit DoLS (Deprivation of liberty safeguards) when people had been assessed as being deprived of their liberty. The manager was applying for these and had 3 left to complete, which had been submitted by the time we concluded this assessment. There was limited evidence that the provider analysed safeguarding incidents to identify root causes or trends. This meant there was a potential risk of recurrence.

We spoke with people to learn more about their experiences of using the service. People’s feedback did not highlight any concerns. Relatives told us they were kept up to date with any changes to their loved one’s care and treatment.

Staff told us that people’s risks were recorded within their care plans and we reviewed records that supported this. They told us how they supported people to be as independent as possible where safe to do so. Staff explained that if changes in people’s mobility were identified this was discussed with them and if needed, referrals to external professionals were made for further guidance and support.

We observed people being involved in making day-to-day decisions such as how they want to spend their day.

Risk assessments had been regularly reviewed, however risk assessments and care plans did not always contain adequate guidance for staff, on how to meet people’s individual risks and health needs. For example, oxygen care, end of life care and specific incontinence needs. This contributed to a continued breach of regulation 12 of the Health and Social care Act 2008 (Regulated Activities) Regulations 2014.

We spoke with people to learn more about their experiences of using the service. People’s feedback did not highlight any concerns about the environment.

Staff did not raise any concerns about the environment in which they supported people. All told us they had received training to ensure they could use mobility equipment safely when supporting people. Staff said they had received training in fire safety and were able to explain where firefighting equipment was located. However, none of the staff we spoke with were able to recall their last fire drill.

We observed the service was well-maintained and tidy. On the first day of our assessment, we noticed a fire extinguisher was not stored safely. However, this was made safe by provider.

The fire risk assessment for the service was being reviewed by a competent person at the time of our assessment. Although there was evidence of monthly checks on fire equipment such as emergency lights and fire extinguishers, there was no evidence of drills taking place at the service. There was no formal emergency contingency plan in place. Each person had a personal emergency evacuation plan (PEEP) in place. We found these were not always up to date and did not reflect people’s needs. This contributed to a continued breach of regulation 12 of the Health and Social care Act 2008 (Regulated Activities) Regulations 2014.

We received mixed feedback from people living at the service. One person said, “Yes, I do like the staff, they’re friendly and kind.” However, some people told us they had to wait for support and found some staff difficult to understand due to a language barrier.

Staff said they felt there was enough staff on duty to meet people’s needs. They told us they had time to provide good care and said they had time to sit and talk with people. Staff told us they felt well supported by the service management team and they received supervision and appraisals. However, the management team were unable to provide evidence of this at the time of our assessment. Staff told us they received training to competently undertake their roles. Some staff we spoke with told us they would like additional training in relation to the management of behaviours that may be challenging due to some people’s care needs within the service.

We observed staffing levels and staff interactions with people living at the service. We saw call bells being answered in a timely manner and staff visible around the service to support people when needed.

The service recruited staff safely, the systems in place were effective to complete checks before staff started work at the service. However, there were not always effective systems in place to identify training needs. There was limited evidence that the provider assessed staff competence in key areas such as moving and handling and medicines administration. This was not in line with the provider’s policy and NICE guidance (National Institute for Health and Care Excellence). This contributed to a continued breach of regulation 17 of the Health and Social care Act 2008 (Regulated Activities) Regulations 2014.

We spoke with people to learn more about their experiences of using the service. People’s feedback did not highlight any concerns they had about the cleanliness of the service.

Staff felt the service was clean and told us they always had access to sufficient Personal Protective Equipment (PPE) to reduce the risk of cross contamination. All told us they had received training in infection prevention and control and would raise any concerns around infection control practices with the service management.

We walked around the service, areas appeared clean and smelt fresh. We observed PPE (Personal protective equipment) being accessible and around the home for staff.

The provider had an infection, prevention and control policy in place. We saw records such as daily cleaning programs in place, however we found gaps in these records that had not been identified by the service and no evidence was provided to us to suggest action had been taken to minimise the risk of areas of the service not being cleaned. This contributed to a continued breach of regulation 17 of the Health and Social care Act 2008 (Regulated Activities) Regulations 2014.

We spoke with people to learn more about their experiences of using the service. People’s feedback did not highlight any concerns they had about medicines optimisation. A relative told us, “[Person’s name] medication is done properly, I have no concern. I have the list and the times they are due”.

Staff involved in the administration of medicines told us they received training on how to support people safely and their competency was periodically assessed. The service was not able to provide us with evidence of recent competency assessments. Staff told us that if people refused their medicines they would continue to try until the person had taken them but were also aware this may need to be escalated to the person’s GP.

The service had several policies related to the administration of medicines. We found the service was not always following their own policies and procedures which put people at an increased risk of avoidable harm. Some staff had received recent medicines training however competencies had not been completed in the last year. We identified recording issues with the service’s electronic medicines system, staff had not received training on this specific system, we advised them to source this. The service had monthly audits. However, this did not identify the service had failed to administer medicines accurately in accordance with the prescriber’s instructions, this placed people at risk of avoidable harm. Following our second day of the onsite assessment the service worked with the Local authority to retrain and support the staff administering of medicines following errors identified. This contributed to a continued breach of regulation 17 of the Health and Social care Act 2008 (Regulated Activities) Regulations 2014.