Abbey Village

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

People were not supported to take their medicines as prescribed. Systems to safeguard people from the risk of abuse needed improvement. Risk assessments did not always contain enough detail to guide staff how to support people to stay safe. Opportunities to learn from incidents were not always maximised. There were not always enough suitably skilled and trained staff to meet people’s needs. The environment was generally safe and refurbishments were planned. Some aspects of infection prevention and control practice could be more robust.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Some people’s feedback indicated staff did not always recognise concerns, incidents or near misses. For instance, one person raised concerns about a lack of engagement from staff after they had choked. Another felt staff had been slow to respond to concerns and recognise them as an opportunity to learn and make improvements.

The registered manager told us they had been working to promote a culture where people could raise concerns and be open and honest. Staff told us if there were any serious incidents they would be discussed, but they were unable to provide any specific examples where accidents, incidents or lessons learnt had been discussed. The registered manager’s responses did not demonstrate good oversight in some areas where lessons could be learned. For instance, where there had been infectious conditions in the home. The management team were unable to locate records or provide details of those affected, so we could not be assured an analysis of the outbreak or lessons learnt had been carried out.

The provider completed a monthly review of accidents and incidents, however these were not always completed promptly and there was no record of the action taken as a result. For example, when we reviewed falls records we identified a pattern in the times of day that a high number of the falls occurred, but there was no evidence any action had been considered by the provider in response to this. Recent safeguarding cases had highlighted some similar concerns to those we found at this inspection. This indicated opportunities to learn from previous issues had not always been taken. We also found the provider failed to learn and respond promptly to feedback given after the first day of our inspection.

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.

We received mixed feedback from people about how safe they felt at the service. Some people told us they had no concerns and would feel confident reporting any issues, whereas others were worried about their safety and wellbeing at the home, including staff’s ability to support them safely in medical emergencies.

Staff and leaders felt people were safeguarded from abuse, although not all staff were able to demonstrate a confident understanding about safeguarding procedures. Leaders were able to explain safeguarding procedures, but they had not always put this into practice and some safeguarding concerns were raised by CQC during the inspection. Staff told us they always gained consent prior to supporting people with care, but staff and leaders lacked understanding of the Mental Capacity Act and how this was applied in practice.

We observed some poor practice during our visits, including medicines practices. This meant we could not be assured people were always safeguarded from the risk of potential harm or neglect.

Safeguarding processes were in place, however they had not been effective at identifying safeguarding incidents we identified during this inspection. There was no comprehensive log of safeguarding incidents and allegations that had occurred, to show what action had been taken in response. The registered manager updated us on the second day of inspection and said they had worked to improve the organisation of safeguarding records. We recommend the provider consider best practice in relation to safeguarding and take action to improve practice and recording in this area. 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 Mental Capacity Act (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We found DoLS applications had been made where required. However, the service was not always working within the principles of the MCA. Records were not always in place to show the provider had assessed people’s capacity to make specific decisions, where this was relevant, or made decisions in their best interests. The records that were available were not clear or decision specific. We recommend the provider consider best practice in relation to the MCA and take action to improve practice and recording in this area.

People told us that they were not always involved in their care planning. Relatives told us some information in care plans was out of date and incorrect.

We could not be assured of the team's knowledge of risk management because some care plans and risk assessments lacked key information. Staff’s knowledge was mixed in relation to supporting people with particular needs and associated risks. The registered manager was able to give some examples where they had supported people to positively take risks in order to develop their independence and experiences, such as one person accessing the community with staff.

Although we saw some positive interactions during the inspection, some observations of practice put people at risk. For example, one member of staff was observed to be using incorrect moving and handling procedures. Following our feedback, the provider advised us they had taken action to address this. Staff were not always present when people needed support, meaning they could not always respond promptly to people’s needs, which increased potential risk.

Risks to people were not always safely managed. Appropriate care plans and risk assessments were not put into place promptly when people were admitted to the service. Care plans did not always contain sufficient information. Monitoring charts for people’s health were not consistently completed, which meant risks could not be effectively monitored. This included food and fluid, bowel monitoring and hygiene charts. Personal emergency evacuation plans were not always in place, or where they were, some contained incorrect information about where people resided, which meant staff did not have access to the correct information to support people in the event of a fire. We identified a breach of regulation in relation to risk management.

Feedback showed that not everyone felt safe within the environment. Some people who required specialised equipment did not feel staff were trained to effectively support the use of this equipment when they were unwell and unable to manage it themselves. One person and a relative had raised concern about an unpleasant smell in one area of the home. Alternative rooms had been offered but the source of the malodour had not been identified and resolved.

Some staff felt areas of the home required upgrading. The head of compliance told us they were in the process of improving the environment. This included plans to replace areas of flooring and kitchen equipment.

The environment was safe and secure. There were several communal areas for people to spend their time. Equipment was in good working order and appropriate checks for equipment were evident. Some areas of the property required refurbishment, but overall, the home was generally well maintained.

The provider had identified some areas of the service which required refurbishment. They had an action plan to complete this work and it was on-going. Equipment and environmental safety checks were completed.

Some people and their relatives expressed that they did not feel there were enough staff available. One told us, “They are not here when I need them” and, “You have to wait a long time for the buzzer to be answered.” A relative told us, “I’m not sure there is enough staff as the staff are always busy doing either the tea trolley or something.” Agency staff did not always recognise or respond appropriately to people’s needs. A relative told us, “They use a lot of bank staff and agency staff and they don’t know my [relative]’s needs. They don’t have a care plan to follow and it is really worrying.” Bank staff are employed directly by the provider on a flexible basis. The registered manager clarified that they only have one bank staff member currently who is used regularly.

We received mixed feedback from staff. Some staff felt there were generally enough staff but others told us they didn't always have time to spend chatting with people, and they felt particular times of the day were busier than others. Comments included, “They (staff on day shifts) just don’t have enough time to spend with people, it's just the tasks that need doing. And I think we need more staff. Sometimes we don’t manage to get everyone up in a morning due to shortage. Someone may be buzzing (in a morning) and I will go to the buzzer. If I am not busy, I help them if I am busy I will ask them to wait a little bit.” The registered manager did not demonstrate understanding of how to use the provider’s tool to assess people’s dependency levels, and the resultant staffing levels required.

People were observed waiting for support. The staff were not always able to support people in a timely way. We observed people who were requiring support with toileting and personal cares and staff were not available to do so, at times causing people to become distressed. Staff were not always proactive in identifying people’s needs and wishes, and we observed they worked in a task-based manner.

The provider did not always plan and implement an appropriate skill mix of staff. The registered manager lacked understanding of how to complete the provider’s tool to assess required staffing levels. This meant they were not effectively determining the staffing numbers needed. Staff turnover was high and the provider had recently recruited a lot of new staff. Recruitment policies and procedures were in place. Checks were carried out, however, some records were not robust. We discussed this with the registered manager who assured us this would be addressed. The provider’s training matrix showed significant gaps in staff training. The provider told us that this was due to them securing a new training provider, so they provided further training records, however these did not include all staff working at the service. There was no evidence that staff received training in relation to stoma care, catheter care and oxygen use, even though there were people using the service who had care needs in these areas. We identified a breach of regulation in relation to safe and effective staffing.

Most people and relatives were satisfied with cleanliness in the home. One person told us they sometimes needed to remind staff to change their bed sheets. Others though confirmed staff kept their rooms clean, and one commented it was always “kept to an adequate standard.”

Staff told us they had access to personal protective equipment (PPE) and confirmed there were domestic staff on duty every day. Some staff raised concerns regarding the kitchen facilities and cleanliness. One also told us,” I don’t think it's clean enough. It’s old carpets and curtains... They do get shampooed but they’re well past their dates.” We received conflicting information from the management team about an outbreak of scabies at the home, including who was treated. This did not demonstrate staff had a confident understanding in this area.

Overall the service was clean, we saw domestic staff were deployed and completed regular cleaning. Flooring was action planned to be replaced in communal areas. Some areas of infection preventition and control practice were observed to require strengthening. We discussed this with the registered manager.

There had been a recent outbreak of an infectious condition at the service and there was a lack of evidence to show what process the provider followed in relation to this outbreak. The registered manager stated that they contacted the public health team and the local NHS IPC team who provided advice. However, there was no recorded evidence available to show this advice had been followed. The provider had an infectious diseases process on their electronic system (which was designed to help identify outbreaks) but there was no evidence of information relating to this recent outbreak on their system. Improvement was needed to demonstrate the provider consistently followed best practice in relation to infection prevention and control. Domestic staff had cleaning schedules to follow and staff had access to IPC training. Training records showed seven staff had not started this training.

Some people and a relative told us they were aware staff had made mistakes with their medicines, and one commented, “They don’t discuss my tablets with me, but they do bring them every day. Sometimes it is later than others.” People were not supported to take their medicines as prescribed. There were gaps in administration records and some people were out of stock of medicines, including critical medicines. People did not always receive their medicines in a timely manner. On both days of inspection, the breakfast medicines round was not completed with sufficient time before the lunchtime medicines round began.

Staff had competency assessments in place, however there was not a consistent approach or documentation used for competency assessment. Staff did not have dedicated time to manage medicines processes, such as ordering and ensuring there were sufficient stocks in the home. Audits had been completed, however they were not done in line with instructions. In addition, an external provider had completed a medicines audit and the actions from this audit had not been followed up or completed. This all demonstrated staff lacked understanding and skills in relation to safe medicines practices.

Room and fridge temperatures were not recorded daily. Medicines were not always disposed of in a safe and secure manner. Controlled drugs records were not accurate, and storage did not meet legal requirements. Handwritten medicines administration records were not always legible, countersigned, or accurate. People’s care plans lacked person-centred medicines information to support staff in administering medicines safely. Person centred guidance was not in place to support people to have their 'when required' medicines when they needed them. People were able to self-administer their medicines, however risk assessments and information to keep people safe were not in place. We saw that medicines trolleys and areas where medicines were stored were not always clean and secure. The home had a medicines policy, however we could not be assured staff understood their role in managing medicines and complying with the homes policies for medicines. We identified a breach of regulation in relation to medicines. Following our site visits the provider was asked for a response about how they would address the immediate risks to people’s safety. This was provided and immediate action was taken to mitigate the initial risks, however time was needed to embed new processes.