Abbey Court Care Home

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

During our assessment of this key question, we found 1 breach of regulations related to safe care and treatment. The risks to people’s safety were not always well managed. Information in people’s care plans did not provide consistent and clear information for a staff group who consisted of a large number of transient staff.

This service scored 59 (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 Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

The majority of people we spoke with gave positive feedback about their experience of the service. One relative said, “Good safe care in a nice clean home, if [Name] is happy, and they are, then that is all that matters. Plenty of staff as well, bells do not ring for long, that is any day or time.” A further relative told us their family member had a sensor mat in their room so staff could monitor them as the person tended to walk with purpose and was at risk of falls.

Staff we spoke with were knowledgeable about how to deal with any safeguarding concerns. They told us they had received training and the management team were always receptive to any issues raised to them. Agency staff we spoke with, showed a good knowledge of what to do if they witnessed any potential abuse of the people they cared for. They told us they would report the concerns to the staff member in charge of their unit and they would also report concerns to their agency to ensure any issues were escalated and dealt with.

Throughout our visit we saw no staff practices which would give us concern for people’s safety.

The principles of the Mental Capacity Act 2005 had not always been followed when supporting people who lacked mental capacity with decision making. The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS) A number of people were supported under Deprivation of Liberty Safeguards (DoLS), their records lacked detailed information to show best interests meetings had been undertaken to support individual decisions around their care in the least restrictive way. This included when bed rails were used or when people had stairgates placed at their bedroom doors. We raised this issue with the home manager and provider, who took measures to address the concerns we raised. When safeguarding incidents were reported managers undertook investigations and worked with the relevant external professionals to address concerns.

Although we found some concerns with the way the risks to people’s safety were managed, relatives spoke positively about their family member’s care. One relative said “Absolutely no concerns on any level. If [Name] was not safe they wouldn’t be there.” A person we spoke with told us how staff supported them with their mobility. They told us they were not very steady when walking so staff supported them with this activity.

Staff told us the information they needed to support people safely was in their care plans.

Measures to reduce the risks to people’s safety were not always in place to support them. During our visit to the service we saw one person who was in bed had a sensor mat pushed under their bed and one bedrail in position on only one side of the bed with a crash mat in place. The bed was not lowered to the lowest height. Our review of their care plan showed a lack of clear guidance of what measures were needed to safely support the person. Because of the high use of agency staff this lack of guidance coupled with what we saw on our visit meant the person was at risk of harm.

The processes for supporting people to reduce the risks to their safety were not always consistently applied for individuals. Care plans for people who had a high risk of developing pressure sores did not have clear guidance on how often they needed repositioning. People’s mobility needs were not always clearly outlined in their care plans. This meant records were not always up to date or had consistent information to support staff to provide safe and effective care. One person had been recorded as having pressure sores and they had been assessed as a high risk of developing pressure sores. However, staff were not repositioning the person on a regular basis, we saw over a 6 week period there were significant gaps in repositioning the person ranging from between 5 and 16 hours. This lack of regular recordings of repositioning combined with the fact the person had developed a pressure ulcer meant that staff had failed to protect the person from harm.

People and relatives we spoke with felt the environment people lived in was safe. One relative told us, “I visit at different times, I have a code and go daily at different times. This is not to catch people out but just to vary the day for [Name]. Every time I go it is the same caring home you would want for a relative.”

Staff we spoke with told us they felt the environment people lived in was safe. There was a maintenance person who dealt with any environmental concerns staff raised to them.

Throughout our visit we saw equipment had been regularly serviced.

The provider had processes in place to manage areas such as servicing of equipment and the environment to reduce risks to people at the service. This included fire assessments and legionella testing.

People who were able to converse with us told us they were happy with staffing levels. They told us call bells were answered swiftly with occasional delays at busy times. One person mentioned seeing new staff “often.”

There was mixed feedback from staff about staffing levels. Some staff felt there was enough, but others felt there were times when they were short of staff and the workload was too high. Other staff felt the use of agency staff was difficult for people as some of them didn’t know people that well. However, agency staff we spoke with told us they were well supported and enjoyed working at the service.

During our visit we saw some examples of staff having time to provide good care to people, but we also saw the were concerns about how staff undertook a mealtime experience on one of the units. There was a lack of organisation, this resulted in a lack of engagement by some staff with the people they were supporting. One member of staff failed to ensure the person they were supporting, drank any fluids with their meal. The person had tried to drink from a beaker themselves when the staff member was bringing their meal to them but was unable to do this. During the time the staff member supported the person with their food they offered the person the drink once and when they refused the member of staff took the drink away. They did not wait and re offer it or ask another member of staff to do so.

We reviewed duty rosters and recruitment processes. The duty rostered showed the managers at the service worked to ensure there was enough staff to support people with their needs. We found over 50% of the staff supporting people were agency staff, some of whom worked regularly at the service. However, we found there was a high level of sickness among staff which meant there were times when new agency staff would need to be called in at short notice. The concerns we found with the lack of consistent information in people’s care plans and the use of such a high number of temporary staff put people at risk of not receiving care which met their needs.

The majority of people and relatives were happy with the cleanliness of the service. One relative told us they had needed to raise a concern about the cleanliness of their family member’s bedroom to the home manager. They told us this had been addressed and there had been no other concerns since then.

All staff we spoke with showed good understanding of their role on preventing the spread of infection.

Although the majority of the service was clean and well maintained, we saw some areas such as undersides of toilet seats which had not been cleaned on a regular basis. There were also one or two rooms where there was damage on the walls from being knocked with equipment used to support people which could harbour bacteria.

Processes were in place to monitor the cleaning and maintenance at the service. However as stated above these processes had on occasion not been effective to maintain cleanliness in some areas of the service.

People and relatives felt medicines were administered safely.

Staff who administered medicines told us there had been a number of problems with the safe management of medicines. However, they told us they had been working with the new clinical lead at the service to ensure any errors were noted and staff were supported to learn from these.

There were some issues of concern around the management of medicines at the service. During our visit we found staff were not regularly checking the numbers of tablets in place for each person. This had resulted in anomalies in relation to people’s medicines. We undertook a full check of diazepam in stock for one person and found there were 5 more tablets than there should have been. This meant although staff had signed to show the medicines had been given we could not be sure the person got the medicine. A further medicines administration record also showed there should have been 100 paracetamol in stock for one person but there was only 75 tablets in stock. There was no record of the missing number of tablets. When staff were asked to complete audits of medicines they did not always follow the audit process correctly. One audit undertaken the night before we reviewed medicines had stated all medicines counts were correct on one unit, but we found two discrepancies with the counts of medicines on this unit when we undertook our own audit. This showed that medicines were not always being properly managed by staff who administered them to people at the service. However, we also saw where the clinical lead had identified areas of concern they had fed back to staff and worked with them to reduce the errors and improve the management of people’s medicines.