Abbey Care Complex

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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Relatives confirmed there was a learning culture at the service. They told us they felt confident, that if they were to raise any concerns, the management would take appropriate action to minimise the risk of repetition. For example, a relative said, “The service is managed well, and we are happy with the care.” A person told us, “I have lived here 2 years, no concerns and staff are supportive and kind. They look after you well.” Records of accidents and incidents were reviewed by the registered manager and actions taken to reduce the likelihood of them happening again. The registered manager understood their responsibility under the Duty of Candour. For example, they said, “My responsibility as the manager is to ensure that [people] and their relatives are listened to and if they have any concerns it is dealt within the appropriate timescale, and where the service has made mistakes, we apologise and learn from this, which helps to improve our service.” Staff confirmed lessons learnt from accidents, incidents and complaints were shared with the staff team. A staff member told us, “We have regular staff meetings, and supervisions where our manager will feedback from any changes from lessons learnt from incidents or complaints.”

Relatives informed us that they were involved with their [persons] move to the home, this included the initial needs assessment process by the management team and with the arrangements for their [persons] transitioning into the home. A relative said, “Staff were supportive, my [relative] settled in well, staff have got to know them well.” The registered manager told us there were systems in place for people transitioning into and out of the service. For example, this included, having an up-to-date policies and procedures, an assessment protocol that identify the persons risks and how the person would like to be supported to help them keep safe from avoidable harm. Staff told us they understood the process of assisting people safely to transition into and out of the service. For example, a staff member said, “We receive information from our manager about the [person’s] needs. This is by written information and verbally. We also build a positive relationship up with the [person], which help with them trusting us with conducting their care and support.

People and their relatives told us that people felt safe living at the home. A relative said, “My [relative] has safety equipment in place to stop them from falling out of bed. The staff sit with my [relative] at night to ensure that they are kept safe.” The provider had policies and procedures in place to protect people from the risks of harm or abuse. The registered manager told us about their systems in place to help ensure that staff understood the organisations safeguarding procedure. For example, the registered manager said, “In staff meeting and supervisions, the management team, will ask the questions, which evaluates staff knowledge. All staff receive regular safeguarding training, which staff also feedback to the team, what they have learnt and if there were any changes to the last training they attended.” Staff understood actions to take if they were to identify a safeguarding concern. Comments from staff included, “I would report to my senior nurse or to the management of any safeguarding concerns” and “Report to the manager and if I’m not happy how it was dealt with, I would whistleblowing to CQC.” The registered manager was clear of their responsibility when there was a safeguarding concern and said, “All safeguarding concerns are fully investigated, and action be put in place to safeguard everyone involved. As part of our procedures, we would inform the local authorities, families and CQC.” During our inspection we observed staff protecting people from potential risks of harm, for example, a person was trying to get up from their chair, which staff quickly assisted them to the area they wanted to go to. The home also had a system in place for checking who visitors were and who they were there to see.

People and relative informed us that they felt staff looked after people well, which included minimising risks to ensure people were safe. A person told us, “I been here for over 2 years and have no concerns, staff now me well.” A relative told us, “My [relative] has been there for 4 years, and staff know him and how they like to be supported.” At the last inspection, we found effective systems had not been established for safely assessing and mitigating risk to people. This placed people at risk of harm. During this visit, we reviewed people’s risk assessments and saw they were appropriately completed to ensure people received safe care and support. Risk assessments were detailed and described the identified risk and the support that was needed to keep people safe. Risk assessment included identified risks such as on falls management, skin integrity, diabetes, and epilepsy. Staff were aware of the importance of having up to date risk assessments in place to ensure risks were minimised and people always received safe care and support. The registered manager told us, “We have a new system that informs us that risk assessments are due to be reviewed, this includes monthly and quarterly reviews. Risk assessments are also reviewed after any incident or concerns that have been identified.” We saw that staff received risk management training, which helped them gain the skills they needed to understand their role in risk management. A staff member said, “There are different types of training, that I have completed, this includes, risk management, fall management, safeguarding and infection control.”

The premises and environment were adapted to meet people’s needs who used the service. The staff and management conducted fire safety checks and audits to ensure the premises was safe to live in. The registered manager told us about the systems that were in place to check the environment was safe for everyone who used the service. The checks included daily walk around the building by management. Any identified issue was reported to their in-house maintenance team, which was acted upon immediately. We saw evidence that audits were completed of the environment and repairs were added to an action plan for the work to be completed. This helped ensure the home was safe for people. We observed the home was safe to live in. The home was clean and tidy, which ensured people were able to move around the home safely. There was an improvement plan in place to identify work to help improve the home.

We saw that there was enough staff working at the service to support people safely. People and relatives, spoke very positively about the staff and management team, they also informed us that they had no concerns about staff that supported people and the staffing levels at the home. A person said, “It is good living here, staff are kind, and I can have a laugh with them.” Another relative said, “Staff are very good and committed to their job.” We saw staff were available when people wanted them, and they responded to people’s requests quickly. The management team conducted spot checks and audits was completed to review that the call bell, was being responded to within a reasonable timeframe. Staff rotas confirmed there were enough staff to support people safely. This included 1-1 support. Employment records showed relevant pre-employment checks, such as criminal record checks, references and proof of the person’s identity had been conducted. Staff had completed key training such as on safeguarding and first aid. Regular supervisions and appraisals had been carried out to ensure staff were supported. Staff were supported in their role. The registered manager told us that staff were supported through staff inductions, training, supervisions to ensure that staff received the support they needed. Staff told us that felt they received regular supervisions and felt the management team was supportive.

At the last inspection, we found systems had been not established to ensure the proper cleaning of the premises was carried out. This placed people at risk of harm. During this visit, we noted the provider had an infection control policy in place and staff had been trained on infection control. Personal Protective Equipment (PPE) was readily accessible, and staff confirmed they had access to PPE when required. A cleaning rota was in place that evidenced regular cleaning of the home was taking place from the housekeeping staff. We saw food hygiene procedures that was being followed by all staff. There was evidence that management and senior staff conducted infection control audits. We observed that the home was clean and tidy in general, and that cleaning was taking place throughout the day of our visit and the cleaning rota was being followed. Staff were seen to be wearing personal protective equipment appropriately, this included gloves and aprons. We saw that there were handwashing facilities available to all using the service.

People and relatives told us that they received their medicines safely. A person told us, “Staff support me with my medication.” A relative said, “Doctors come and visit my [relative] to review their [medicines] to ensure everything is fine.” The provider had recently implemented a new electronic online system for their medicine administration records (MARs), which showed that medicines had been administered as prescribed. Medicine audits were completed on the system, which gave a clear record of what medicine was in stock and when it needed to be re-ordered by the pharmacy. This helped ensure that people received their medicines safely and on time. We saw evidence that staff had also been trained in medicines management and had competency assessments to ensure they were competent to manage medicines. Staff told us they were confident of managing people’s medicines and that the training they received was of a good standard that helped develop their skills and knowledge. The registered manager was able to demonstrate that the provider had systems in place, which ensured medicines were managed safely and that there had been improvement made since the last inspection. This included introducing a new electronic online system, which staff was positive about.