Abbeyfield Lear House

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 good. At this assessment the rating has changed to requires improvement.

This meant people were not always safe and protected from avoidable harm.

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.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice. For example, the provider did not investigate events including incidents and accidents to establish the cause, trends and patterns and ways to prevent further occurrences. In addition, there was no evidence lessons were learnt and shared with staff to improve their practise.
Monthly audits of safety-related events, including accidents and incidents, were not sufficiently robust to support a culture of continuous learning. We identified four serious incidents that had been documented in individuals’ daily notes but were not appropriately recorded in the incident log. As a result, these incidents were not recognised as notifiable events and were not reported to the Care Quality Commission, as required. This failure to accurately log and escalate serious incidents demonstrates that the service was not effectively learning from events or using them to improve safety and care. The lack of a reliable and reflective incident reporting system limited opportunities for organisational learning, accountability, reduction and prevention of known risks.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services. For example, when one person was admitted to hospital there was no evidence of communication with the hospital to ensure relevant information was shared. The lack of communication with healthcare partners during transitions, such as hospital admissions, meant that important information was not shared in a timely manner. This increased the risk of unsafe care and poor outcomes.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. Staff had been trained in safeguarding and were able to explain how to identify and report safeguarding concerns. However, the provider did not share concerns quickly and appropriately. For example, serious injuries were not always reported to the appropriate safeguarding authorities, as required. During the assessment period, the Care Quality Commission identified two safeguarding concerns that had not been recognised or reported by the provider. Additionally, serious injuries were not consistently reported to the relevant safeguarding authorities, contrary to statutory requirements.
However, the registered manager was responsive to our feedback and provided assurances they were in the process of implementing systems to ensure that incidents and accidents were properly analysed and promptly reported to the relevant agency.

The provider did not always work well with people to understand and manage risks. For example, care records and risk assessments failed to reflect the level of care needed or delivered. In cases where care plans indicated that individuals should increase their fluid intake, there was no evidence of daily fluid monitoring to support this. One person had recorded in the medication care plan, administer twice a day with 200 mils of fluid however the total daily intake for fluid was recorded as 200 mils for a full day.
We saw an air flow mattress used by a person at risk of skin breakdown was set incorrectly placing them at risk of developing pressure wounds.
There were instances where advice provided by healthcare professionals was not followed. In situations where individuals chose not to follow this advice, there was a lack of documented evidence to demonstrate that the provider had undertaken a comprehensive assessment to ensure the person fully understood the associated risks. Additionally, there was limited evidence of alternative strategies being explored to support positive risk-taking
During our review of care plans, we observed that while some records included documented discussions indicating individuals' involvement in planning their care, this was not consistent across all files. Furthermore, there was no clear evidence that people using the service, their family members, or relevant professionals were actively included in the review and updating of care plans. For example, in one case involving a best interest meeting about the use of assistive technology to help prevent falls, there was no indication that their family member or involved professionals were consulted or included in the decision-making process.
Family members told us, "I am involved in all decisions" and "Involved in all decisions and care planning right from the beginning." A member of staff told us, "I include relatives in decisions and planning" and "We hold monthly relatives' meetings."
 

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. For example, floor coverings in some parts of the home were unsafe, posing a risk of injury from trips and falls, such as a carpet strip had lifted outside communal bathrooms, and on the stairs the carpet had lifted away from the stair. We saw bleach was left on a handrail; however, this was dealt with immediately by the registered manager.
Some items of equipment used by people were unsafe including a shower chair with faulty brakes.
People’s personal information was not safely stored. We found personal information and health conditions attached to a kitchen hatch within the dining area accessible for all, including visitors.
An emergency grab bag containing essential items for evacuation was readily accessible in the office, along with a copy of everyone’s Personal Emergency Evacuation Plan (PEEP). These plans were regularly reviewed and updated. Fire safety instructions, including zone-specific details, were clearly displayed in the reception area.
 

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs. For example, the provider had not completed dependency assessments to ensure there was enough staff to safely meet people’s needs. Staff had mixed views regarding staffing levels. Staff told us “Staffing levels are ok at times, mostly there is enough staff, but we could sometimes do with an extra carer on, but we manage well” and “There are a few people who need 2 carers.”
We observed seven individuals, including those using walking aids, seated in the lounge for an extended period without any staff presence. The absence of supervision posed a potential risk to their safety and wellbeing, particularly for those with limited mobility who may require assistance. Without staff nearby, there was an increased risk of falls or delayed response to any incidents.
Recruitment records were inconsistent, with some containing incomplete application forms, raising concerns about the robustness of the recruitment process.
A recruitment risk assessment completed by the provider on 10 April 2025 stated references had been received and an application had been submitted to the Disclosure and Barring Service (DBS). However, evidence reviewed during the assessment indicated that references were not obtained until 22 April 2025, and the DBS application was also not submitted until that same date. This discrepancy suggests that the information recorded in the risk assessment was inaccurate at the time it was completed.
 

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.
For example, infection prevention and control (IPC) practices at the service were not always safe or hygienic. There was a strong, unpleasant odour in parts of the home including people’s bedrooms and some toilets were heavily stained.
Personal protective equipment (PPE) was not always disposed of correctly we observed this being disposed of in wastepaper bins within bedrooms and the dining room. A red laundry bag containing soiled clothing was left on the dining room floor.
A water dispenser in the dining area was heavily scaled and dirty. Items of equipment used by people were visibly unclean. This included chairs which had a build-up of food debris and sweet wrappers underneath the cushions and unclean pressure-relieving cushions. Cleaning equipment such as mops outside the kitchen were stored incorrectly, increasing the risk of cross-contamination.
 

The provider did not make sure medicines and treatments were safe and met people’s needs, capacities and preferences.
We found multiple concerns regarding the management of medicines. One person was administered medicines that had passed their expiry date. Additionally, expired medicines, including eye and ear drops, were found stored in the fridge and several creams were found to have been opened without a recorded opening date and passed their expiry date. This raised concerns about the effectiveness and safety of medicines in use.
One person was not administered their pain relief medicine in line with the prescribed instructions, which stated it should be given four times a day. We identified it was being given only twice a day. Furthermore, one person did not receive their time-sensitive medication on the correct day. This medication specifies to be given on the same day once a week. Not doing so risks the medication not working effectively and increases the risk of side effects.
We found a tablet in a person’s bed; we alerted the manager who confirmed this had been signed for on the medication administration record (MAR) as being given.
The provider carried out regular audits of medicines use and assessed staff competency in administering medicines. However, these processes were not sufficiently effective in promoting safe and effective medicines optimisation. Despite audits and competency assessments being in place, we identified instances where medicines were not administered in accordance with healthcare professionals’ directions. In some cases, people missed doses because their medication schedules had not been reviewed or adjusted in response to changes in their daily routines, such as being asleep during planned administration times.