Abbey House Nursing 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

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 improved to good. This meant people were safe and protected from avoidable harm. The registered manager had made the improvements required from the last inspection in relation to safety, medicines, environmental risks and records. The service is in breach of 2 legal regulations in relation to not reporting all allegations of abuse to safeguarding for them to consider if any further actions were required and failing to notify CQC of all allegations of abuse. There was a reporting culture, but it was inconsistent in application. The registered manager was responsive to our feedback and immediately addressed these issues by reviewing and strengthening existing processes for reporting and recording. However, these were not fully embedded yet. These were the only areas of concern identified.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not always have a proactive culture of safety in relation to aspects of some processes. For example, staff and leaders told us investigations took place following incidents. However, the resulting actions including any learning, referrals made and follow up actions taken were not always immediately clear from the incident forms and audits completed. Leaders told us they completed trends analysis of incidents and feedback they received, and additional staff training was then provided as required. We found the processes in place though were not always sufficiently robust to support staff to identify any patterns, themes or trends for incidents that may re-occur. However, the registered manager was open, transparent, and wanted to drive improvement at the service and took prompt action to amend both the incident form and the trends analysis record. People told us they felt confident about raising any issues. Staff said they were encouraged to raise any safety concerns and felt able to do so. Staff said if there was an incident they would document this, “On the incident form which is then given to the nurses and the manager depending on what the situation is."

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. Staff told us there were effective communication processes to ensure they had access to all the information they required when people moved in. People were referred to a variety of professionals when required for their care. Staff had access to processes to assess people's health, monitor them and quickly identify any signs of deterioration. Staff were able to produce a 'hospital pack' of essential information to be sent with the person if they required admission to hospital. People's care needs were re-assessed upon discharge from hospital and any critical information was shared with staff.

The service did not always share safeguarding concerns at the time with the local authority and CQC. For example, although leaders reviewed incidents and complaints and took action to keep people safe from abuse. They had not always then identified that a safeguarding alert should also have been raised with the local authority, for them to assess if any further actions were required. Leaders had not always submitted safeguarding notifications to CQC when they reported allegations of abuse to the local authority, or when they had been aware by the local authority of safeguarding concerns raised about people in their care. However, the registered manager took prompt action after the site visit to rectify this. People were observed to be well cared for and treated well by staff and clearly felt safe with them. Staff spoken with knew what to report in relation to any concerns about abuse and had completed relevant training. Staff said, “We’re always visually monitoring everything and everyone around us. I would look out for changes in behaviour, a change in the way someone carries themselves, if they appear unhappy or quiet. I would report anything to the team leader or nurse if I had concerns.” Leaders and staff both had a clear understanding of their responsibilities in relation to the Deprivation of Liberty Safeguards (DoLS) and legal processes had been followed.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. People and relatives said any risks were well managed and their choices were respected. We saw a person had equipment in place to mitigate the risk of them falling out of bed. The registered manager told us they had discussed with the person how they wanted the risk to be managed, and the equipment provided reflected their preferences and choices. Staff had enabled another person to move to an independent living scheme. People's risk assessments were person centred and detailed and staff told us they were updated immediately if there were any changes.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The service was located in an older property which had several flights of stairs, particularly upstairs. Leaders took into account people's mobility needs when considering where to accommodate them and people who were more mobile were accommodated downstairs. Staff ensured relevant safety checks were completed as required in relation to equipment and the environment. For example, staff ensured checks were completed on equipment such as air mattresses. Staff followed the processes in place to ensure any safety issues were identified and addressed.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. People said there were enough staff, who all treated them well and who understood how to look after them. We observed overall staff including ancillary staff were very caring, responsive and attentive to people. Staff were well trained in their role by the on-site training manager and received training which was appropriate and relevant to their role. Staff said they were supported in their role and encouraged with their professional development. Leaders ensured pre-employment checks on staff’s suitability were completed.

People said they were kept up to date if an outbreak of an infection occurred. The premises and equipment were observed to be clean and hygienic and were cleaned in accordance with the provider’s cleaning schedules. Staff had received relevant training in infection control and had access to up-to-date policies, which reflected best practice guidance. Staff understood the actions to take if an infection broke out.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened. People told us they were provided with their medicines including those taken 'as required' or for pain relief as needed. People only received covert medicines in accordance with legal requirements and in consultation with relevant professionals. Staff told us they were suitably trained in medicines administration, and their competency was assessed. Leaders ensured people’s thickeners were stored in communal areas were secure. However, they had not completed a risk assessment for those stored in people’s bedrooms. The registered manager took immediate action to address this once brought to their attention.