• Care Home
  • Care home

Abbeyfield Loughborough

Overall: Requires improvement read more about inspection ratings

42-44 Westfield Drive, Loughborough, Leicestershire, LE11 3QL (01509) 266605

Provided and run by:
Abbeyfield Loughborough Society Limited(The)

Report from 6 February 2024 assessment

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Safe

Requires improvement

Updated 2 May 2024

People and relatives were complimentary about the service. Feedback gathered was unanimously positive about the new manager and people were happy to see the changes which were being made to the service. Some concerns continued around the management of risk and there remained a breach in regulation to this. We also found peoples capacity to consent was not always fully considered when managing and putting mitigation in place to manage risk, including adherence to legal safeguards and the service remained in breach of this regulation. We observed differing approaches to people from permanent staff and agency staff, who knew people less well. Although the service continued to rely on the use of bank and agency staff, there had recently been a number of new staff recruited. We found they were no longer in breach of the regulation relating to safe staffing numbers and this improvement was particularly evident when people required additional support. People felt safe living at the service and there were improvements in how any safeguarding concerns were assessed, reported and managed. The service was no longer in breach of the regulation related to safeguarding people and protecting them from abuse.

This service scored 44 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Learning culture

Score: 2

People and relatives were complimentary about the service. Feedback gathered was unanimously positive about the new manager and people were happy to see the changes which were being made to the service. Relatives felt they would be listened to if they had concerns. One said, "None of the carers fob you off; if you tell them an issue they sort things." The provider told us they have started to implement a new electronic care planning and recording system. This will mean the registered manager can identify issues within the service more quickly, and make any required changes.

The new manager told us they were committed to making improvements to the service. They had already began making changes across the service, however, these do need further time to ensure they are fully embedded. Following the last inspection, the local authority have continued to offer support and guidance to the service. They have reported on some improvements and are continuing to provide ongoing assessments of quality and support to improve.

Safe systems, pathways and transitions

Score: 1

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.

Safeguarding

Score: 3

People were protected from avoidable harm and abuse. One person said, "I am very happy here - the staff are nice to me." Another told us, "It is as good as any hotel."

Staff had received training in safeguarding, and understood how they should report any concerns of abuse.

People were observed to be supported by staff safely, and in a way which met their needs.

There were improved safeguarding processes and awareness amongst the staff and leadership teams. We found there was an improved assessment of any incidents and timely escalation to other agencies to ensure the potential of harm or abuse was mitigated. There was analysis of any incidents to ensure learning and to protect people from any ongoing risk of harm.

Involving people to manage risks

Score: 3

People felt safe living at the service. One person said, "If you have a tumble, [staff] will help you up."

Staff told us how they kept people safe, and responded to them in a way that met their needs.

We observed inconsistency in the management of risk. Some observations showed safe assistance from staff for people to change their position or mobilise, however, we also observed 2 people who complained of being cold. Neither of these had the heaters turned on in their bedrooms, and were not dressed in appropriate warm clothes. This had not been identified prior to the inspector arriving on site and raising these concerns with the manager.

Whilst the provider had made improvements since our inspection, some areas of concerns remained. For example, there was not always due consideration to people's capacity to consent to risk reduction strategies and the provider did not always take account of legal conditions in place to protect people when their liberty was restricted.

Safe environments

Score: 1

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

Safe and effective staffing

Score: 2

People received good care from permanent staff who knew them well, however, the service was heavily reliant on bank staff and agency staff. The agency staff did not know people well. A relative said there were days when staff were not visible around the service. Another relative said, "Staff are really good and they know residents well; agency staff are great too, but they don't understand the individual needs in the same way, but they do have some that they use frequently, which helps."

The manager told us they had undertaken a recruitment drive and had employed several new staff. Staff told us there was an overuse of agency staff, and some shifts can be only 1 or 2 permanent staff, with the rest of the shift being covered by agency staff.

We observed an incident where a person did not have their needs met by agency staff. We reported this to the manager to enable them to address the concerns. Positive interactions were identified between permanent staff and people in communal areas, however there were some concerns with the approach of some agency workers, as they lacked the engagement and interaction people needed, particularly those living with dementia where effective communication was essential in providing the reassurance and comfort needed.

Staff were recruited safely and received training appropriate to their role.

Infection prevention and control

Score: 1

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

Medicines optimisation

Score: 1

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