Abbey Ravenscroft Park 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

We assessed a number of quality statements in the Safe key question and found areas of concern. The scores for these areas have been combined with scores based on the rating from the last inspection, which was good. We identified a breach of the legal regulations. The provider had not always identified and managed risks to people's safety and wellbeing so they were supported to stay safe. The provider had not always managed risks to people’s safety and wellbeing by appropriately maintaining the premises at all times. Staff supported people to take medicines safely, but the medicines management arrangements were not always implemented consistently. There were sufficient numbers of staff to support people. Staff were provided with assorted training and supervision so they could support people safely. The provider used appropriate recruitment procedures to employ suitable staff. The service supported people to be safe from potential abuse.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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

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 told us they felt safe with the staff who supported them. A person said, “I feel safe here.”

The staff we spoke with knew how to recognise and respond to safeguarding concerns and had completed training on this. some staff were not always clear on how to report concerns to statutory services such as the local authority if needed. Managers had a good understanding how to respond to allegations of abuse and neglect.

We observed some poor practices during our visits, including the condition of some people’s rooms and not always treating people with dignity. This meant we could not be assured people were always safeguarded from the risk of potential harm or neglect.

The provider had policies in place for responding to safeguarding concerns, but these were not always clear about reporting some pressure sore concerns to statutory services or agreeing when to investigate a concern. The provider reported concerns to the local authority and the CQC. The provider recorded and monitored safeguarding concerns to help ensure these were responded to appropriately.

People and relatives told us they felt safe. One person commented, “The kind nurses help me to feel safer.” However, the provider had not always identified and managed risks to people's safety and wellbeing so they were supported to stay safe at all times. Some people’s care and risk management plans described actions to promote their safety but some people’s plans did not always set out sufficiently how to mitigate risks to their safety. For example, when supporting a person who smoked, at risk of falls or when they experienced dementia related distress.

The provider responded promptly to the risk management issues we raised with them. They told us they were improving how they used risk management and audit processes and the issues they identified acted upon. They had engaged an external auditor to review health and safety at the home as well.

We observed some support practices that did not always manage risks to people's health and safety sufficiently. For example, we saw fire doors propped open, an area designated for residents to smoke was not appropriately equipped for this and we saw staff dispose of a smouldering cigarette in an unsafe manner. We raised these issues with the manager so they could address them.

The provider used a range of audits to monitor people’s risk management plans and the safety of the service, but these were not always effective. Those which were in place were not always implemented robustly enough and had not addressed the things we found. For example, there were fire safety arrangements in place but risks presented by a person’s smoking had not been sufficiently managed.

The provider had not always managed risks to people’s safety and wellbeing by appropriately maintaining the premises at all times. For example, we found an unsecured window on the first floor and tripping hazards from staff using vacuum cleaners. However, some people and relatives said the environment had improved recently. Their comments included, “I feel safe in my room,”, “I did notice a lot of work around the home, they started doing room by room, painting, then deep cleaning” and “Now there is nice tablecloth on all tables in the dining room, fresh flowers … and many other residents have new furniture delivered.”

The provider explained they were making improvements to the environment following the findings of the local authority and the findings of this assessment. Between our visits they painted some people’s bedrooms, tidied the garden and fitted a blind to a person’s shower room.

Some people were living in unkempt environments with bedrooms looking out onto dirty spaces, some had stained bedding, damaged furniture and missing curtains. Some people’s bedrooms were personalised while other people’s rooms were bare, with no personalisation or meaningful stimulation evident for them, especially those living with advancing dementia. Some areas were in need of refurbishment, such as damaged paintwork on walls. Some care equipment needed amending or repair, such as a frayed cable on a call button unit, so it did not prevent a risk to people.

Staff completed a daily equipment check and the provider had recently introduced an improved environmental audit. The provider had a refurbishment plan in place as well following the concerns identified by the local authority. However, these had not addressed all the issues we found when we visited. The provider had not taken continuous actions to maintain and improve the home environment as part of their routine assessment of the home. The provider also completed checks to maintain water temperatures, lighting and lifts.

People spoke positively about their experiences with staff and some said this had improved recently. A person told us, “The carers are all very young but they are doing good job [and] the nurses are very good.” A relative said, “I never mentioned [an issue] before to anyone [as] it was awful to talk to any staff, I think new staff are employed and they are much more friendly.” There were enough staff to support people to be safe and meet their needs.

The provider explained how they monitored staff training and required staff to complete mandatory training before they provided care to people. The provider was in the process of recruiting a new permanent manager and a new clinical manager.

We saw some staff providing attentive and caring support to people. However, staff were not in receipt of all the training and support to always keep people safe and promote person-centred care, especially in relation to preventing people from choking who received specialist diets, and responding to the poor condition of some people’s bedrooms.

Staff received an induction and periodic supervision with a senior staff member or a manager. The provider monitored training and supervisions taking place. However, some staff lacked training and support to always provide safe food preparation and care to people who had swallowing difficulties. The provider used appropriate recruitment procedures to employ suitable staff.

People’s rooms and the communal areas were cleaned regularly and a person said, “My room is cleaned every day.” A relative told us they felt cleanliness and tidiness in their family member’s room had improved recently. However, we found some areas of the environment’s cleanliness needed addressing.

We discussed the cleanliness issues with the provider so they could address these. The provider had an action plan in place to make improvements to the home environment.

We found some odours of stale urine and water and stained bedding in some people’s rooms. We saw damage to some handrails the paintwork of some handrails and to the surfaces of some mobility hoists which affected how clean they could be kept. The provider took action to address the infection control issues after we raised these to them.

The provider has policies and procedures in place for preventing and controlling infection. These included regular checking of the home to ensure it was being kept clean.

Staff supported people to take their medicines as prescribed. People and relatives we spoke with did not have concerns regarding the help people received to take their medicines.

Staff completed medicines support training and the provider assessed their competency to provide this support safely. Staff used medicines administration records to note when they did support a person with their medicines.

The provider had systems in place to support people to take their medicines as prescribed. However, these were not implemented at all times. On one occasion staff had not followed all processes for returning controlled drugs to a pharmacy. The manager addressed this promptly when we discussed this with them. There were not always risk management plans in place for supporting people with high-risk medicines, such as anticoagulants. We raised this with the managers so they could address this. The provider completed regular medicines support audits to check people were receiving the medicines as required. The provider completed regular medicines support audits to check people were receiving the medicines as required.