Abbeyfield Loughborough

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

Although the provider had made improvements to the management of people's safety and taken action to learn from safety incidents, further improvements were needed to ensure sufficient resources, including sufficient deployment of staff, were always available to keep people safe. People did not always receive timely care. This was a breach of Regulation 18 (Staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Staff records did not always evidence peoples' needs had been met in line with their care plan. Improvements were needed to areas of the environment to ensure these were safe and fully accessible. There were safe systems for appropriate and safe handling of medicines; though further improvements were needed to records and medicines audits. The provider's safeguarding processes were effective and staff understood these. Infection prevention and control was well managed.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People and their relatives felt staff responded to concerns around safety and these were acted on in a timely manner. People's comments included, "I absolutely feel safe here," and "I get the help I need. Staff know what I can do and help me with what I can't do so I always feel safe." A relative told us, "Staff keep me well informed about [Name’s] care and if anything happens they telephone me or tell me when I visit. [Name] has recently had a couple of falls in the night. Staff had called NHS 111 and arranged for the GP to assess [Name] and I have been kept informed."

The manager understood their roles and responsibilities for a proactive, positive and learning culture. Staff told us they had regular communications from the manager to identify if a change in practice was identified for people. Flash meetings were held daily with managers and heads of teams to ensure outcomes were communicated and agreed. Some staff felt managers were not fully proactive in listening to staff feedback to ensure lessons were learnt and timely improvements were made.

There was a positive learning culture in progress at the time of our assessment; accidents, incidents were analysed for themes, patterns and learning opportunities and discussed with staff. Care records were updated following incidents and accidents and audit trails allowed learning and change in practice if identified through trends patterns and themes.

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 were protected from the risk of abuse. The provider's safeguarding processes were sufficiently robust; safeguarding concerns were managed appropriately and actions implemented to ensure people were safe. Staff had received safeguarding training, had access to safeguarding policies and procedures and understood their role and responsibility to protect people from abuse and avoidable harm.

People and relatives provided mixed feedback about their involvement in risk taking. One person told us, "I like to spend time outside when the weather was good and had asked the staff this morning if I could be taken into the garden. I like to get out of my room in the morning and go back after lunch to rest. I found that my request hadn't been passed on and I have been left in my room until lunchtime which upset me. You never know who is going to be on and there’s no continuity with staff." A relative told us, "I’m not sure the home encourages independence because I’ve had to push for [family member] to get outside and walk in the garden as this helps to calm them." Other people and relatives felt involved and consulted in decisions about risks associated with their care and felt their wishes and choices were listened to. A person described how staff only helped them to do the things they struggled to do for themselves as staff knew it was important for the person to have their independence.

Staff provided mixed feedback around the management of risks for people. Some staff felt people were not always safe due to the impact of a recent reduction in numbers of staff deployed. A staff member told us, “People are safe here but only at a basic level; their higher level needs are not met because there has been a reduction in staff. We can't always meet their needs as quickly as they need us to or provide the constant supervision to keep people safe.” Other staff felt there had been improvements in the management of risks but there were still inconsistencies in staff support which meant people were waiting to have their needs met. Managers took action in response to our feedback immediately after the assessment; actions included increasing staffing levels to ensure people’s needs were met in a timely way.

We observed people who walked with purpose were restricted throughout the environment. We observed people indicating they wanted to walk into the courtyard garden area. Staff were constantly redirecting people from the garden and back into the lounge area due the garden being unsafe if people were not observed, which resulted in people becoming distressed. This meant risks were being managed by environmentally restricting people to keep them safe. We observed a person was being restricted to remain in bed as staff felt they were at risk of harm when seated. We raised this potentially unlawful restriction with the registered manager who took immediate action to address this.

People’s risks were screened and assessed. Where people had identified and known risks, risk assessments were completed, identified actions were put in place to mitigate risks and keep people safe. People with distressed behaviours had positive behaviour support plans in place with guidance for staff to follow. Risks associated with people's individual needs were assessed and planned for. Overall guidance for staff of how to mitigate risks was detailed. Whilst there was good evidence of cross referencing in people's care plans, monitoring tools and daily care notes were not always sufficiently detailed or factual. Information in daily care notes was not what we observed throughout the day. Staff daily care records did not always evidence people’s needs had been met and care plans were not always updated in a timely manner.

People were happy with their rooms and felt safe when staff supported them to reposition and mobilise with equipment. People and relatives felt frustrated at the lack of access to all garden areas. A relative told us, "People have access to the side garden but the other garden area is unsafe because of the risk of people falling. We have been waiting over 12 months for this area to be made safe, but we are still waiting."

Managers understood the main garden being inaccessible caused a restrictive environment that impacted on people’s freedom to move about their home. The management team had agreed to have works completed on the garden area to ensure people could move around the garden safely, however, this had not been agreed prior to our visit.

The maintenance team had completed various works about the building to ensure it was safe for people. Recent changes to the environment had been made to make some areas of the garden was accessible for people to use. Additional gates and fences were installed to ensure people were safe and a review of the alarm panel had been completed with the manager to ensure the zones for the external door alarms were correct.

Managers completed regular monthly and six-monthly audits throughout the environment. Managers walk rounds, infection, prevention and control and health and safety audits had been completed. Maintenance logs had recorded servicing was in date and completed regularly. However, some of the environment was restricted, which impacted on people. Communal areas of Ingleside were not personalised and did not provide stimulation or encourage interaction for people living with dementia. The management team had plans to make these areas of the garden safe so people could walk freely about their home.

People and relatives felt staff were usually visible, but there were occasions when staffing was not sufficient to meet people's needs. A person told us they were able to ask for help and staff responded to this without them having to wait too long. A second person told us, "Staff are very good and always help me." A third person told us, "I need staff to help me and I have had instances where I have had to wait some time for help. This is really upsetting, especially if I have soiled myself." A relative told us, "I think there is enough staff around now. It's been a noticeable improvement since the changes and the new manager." A second relative told us, "There do seem to be quite a few different carers; there’s always someone we haven’t seen before. However, whenever we visit we always see carers interacting and sitting and talking with residents".

The registered manager told us they had recently reduced staffing levels due to a reduction in residents. Staff told us they felt they were short staffed on Ingleside and struggled to meet the needs of people due to their dependency and having to support people over 3 floors. People told us this had impacted on them getting support when they asked for it. People did not always have their needs met in a timely manner due to staff deployment. The registered manager immediately reviewed staffing levels and increasing deployment at Ingleside in response to this feedback.

During the assessment we observed there were not always enough staff deployed at Ingleside, particularly where people required care and support. We observed people having to wait for support to mobilise, go to their room or change positions. There was a lack of engagement and interaction between people as staff were rushing to complete tasks. This evidence supported a breach of Regulation 18 (Staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The provider had ensured safe staff recruitment procedures were in place and followed, including pre-employment and identify checks. Staff training compliance rate was good, however, the provider's training matrix indicated some staff training had not been completed or kept up to date. The registered manager was aware of this and was speaking to the relevant staff to ensure this was addressed promptly. Staff told us they did not receive regular supervisions. The registered manager maintained a supervision and appriasal matrix but this did not fully assure us that staff were receiving regular supervisions or had regular opportunities to discuss their work, training and development needs.

People and relatives felt the service was clean and hygienic. People's comments included, "it’s good because everywhere is clean and the equipment is clean" and "I like my room as staff keep it clean and tidy." Relatives felt there had been improvements in cleanliness and processes in the last few months.

The registered manager told us all actions identified in a recent infection prevention and control audit undertaken by an external agency had been completed. Staff had recently completed training in personal protective equipment. The registered manager undertook regular audits and checks in infection prevention and control as part of their quality assurance process.

The buildings were clean and tidy and free from infection. There was plenty of personal protective equipment available to staff in people’s rooms and in stations around the buildings. The provider had ensured actions identified from recent audits were implemented, for example we saw a new laundry trolley had been purchased as a result of the registered manager's quality assurance.

The provider had robust procedures and systems in place to ensure the risk of infection was managed and mitigated. The provider had achieved a positive outcome from a recent infection prevention and control audit which evidenced the improvements they had made since our last assessment.

People and relatives felt their medicines were managed safely and staff were pro-active in ensuring people's medicines were effective through regular medicine reviews. A person told us, "I don't take many medicines, but the senior staff help me take them each day correctly." A relative told us, "[Name of staff member] recommended, in consultation with the GP, that [family member] change their medication. As a result of this, the transformation in [family members'] condition has been brilliant". A second relative described how staff worked with them to ensure they had their family members' correct medicine to take when they went on visits.

Staff told us they received training to manage medicines and had their competency checked to ensure they could safely administer medicines. Staff knew and were able to describe the process they would follow if there was a medicines incident and were confident in working with the GP to ensure people's medicines were regularly reviewed. Training records were provided to evidence this. We observed staff were kind and caring when supporting people to take their medicines.

The provider had safe systems for the appropriate and safe handling of medicines. Processes ensured medicines and treatments were safe and met people’s needs. People's capacities and preferences were enabled by them being involved in medicine care planning, including when changes happened. However some improvements were needed to ensure instructions from specialists, for example the timing of time critical medicines, were clearly followed and medicine audits were regularly undertaken. For example, we found a time critical medicine for a person was not being administered at the times recommended by the prescribing specialist. Additionally, we found a person required blood pressure monitoring for 7 days following a fall but staff had not followed this healthcare advice. Staff carried out monthly and weekly medicines audits and a medicines action plan was in place to address identified issues. However, for 3 months prior to our visit, audits and checks had not been undertaken regularly. People’s allergies were accurately recorded and people had individual medicines plans which detailed how they liked to take their medicines and the support they needed. ‘When required’ (PRN) medicine protocols were in place to help staff give these medicines correctly and contained detailed personalised information to support the safe administration of these medicines.