Abbeydale - Derby

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 some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to people’s safe care and treatment.

This service scored 56 (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. They did not listen to concerns about safety and did not investigate or report safety events in a timely manner. Lessons were not learnt to continually identify and embed good practice.

Incidents of bruising and skin tears had not always been identified, reported and investigated in a timely manner. We identified a person with a bruise and no investigation as to its cause had taken place at the time of occurrence. An attempt to investigate this retrospectively was not successful. For another person, staff had recorded 2 incidents of when a skin tear had been identified, one month apart. However, there had been no investigation as to how the first incident occurred at the time of injury and therefore there had been no identification of how to prevent a recurrence. This meant the provider had missed opportunities to understand the potential causes of bruising and skin tears and to learn lessons to help people have safer care.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

People and their relatives told us they were supported when they accessed other healthcare or when they had moved into Abbeydale – Derby. One person told us, “When I go to an appointment a carer goes with me. They are very good. By and large they are very good.” Whilst a relative said, “When [family member] came in [to Abbeydale – Derby], the staff came round to them more often, to check they were alright.” This helped to ensure people received support when they transitioned between services or accessed the healthcare they needed.

The provider had not always worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They had not always concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

People felt safe living at Abbeydale – Derby. One person told us, “I feel safe here. Better than living on my own.” Whilst a relative added, “It’s a relief that [family member] is here now, I feel they are safe.”

Staff had completed training in safeguarding and understood what actions to take if they identified any signs that could indicate a person was at risk from abuse or avoidable harm. Staff had made safeguarding referrals to the local authority and notified the Care Quality Commission (CQC) when needed to help ensure people were safe. However, not all incidents of bruising and skin tears had been investigated at the time of occurrence which meant actions to help people remain safe had not always been taken in a timely manner.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Care plans and risk assessments did not always show how risks to people’s health should be managed. For example, prior to our assessment, one person’s care plan had not been updated to show a specific health condition and the GP’s advice on this. Another person’s care plan had basic information about their health condition and how this could deteriorate, but no description of what the signs of this deterioration could look like to help ensure early identification. A person told us details of their dietary needs however, these details were not fully reflected in either their care plan or the information held in their kitchen records. Not all staff we spoke with were aware of people’s health conditions. This meant people were at risk of inconsistent care as care plans and risk assessments were not always in place for people’s care needs.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Actions had been taken to ensure people’s home environment was safe. For example, windows were restricted so they could not be fully opened and create a risk. Other areas of the building that contained potential hazardous items, such as the laundry and kitchen were kept secure. Checks were made on water safety, and fire drills were completed. These helped to ensure the home remained a safe environment for people.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Most people felt there were enough staff. For example, one person felt there could be more staff. They told us, “I’ve only one complaint. We need more carers. They are always so busy. Sometimes you have to wait, particularly at mealtimes.” Our observations during the assessment showed staff were able to attend to people in a timely manner.

Checks had been made on staff before they started work to help ensure they were suitable to work in care. Staff were trained in areas relevant to people’s health care needs and they received on-going supervision and training.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

People’s home environment had been kept safe and regularly cleaned. People and relatives shared this view. One person told us, “It’s friendly, clean, homely.”

Staff with responsibilities for cleaning understood how to help prevent and control the risk from infections, for example by using colour coded cleaning clothes. They told us they had enough cleaning materials, that these were effective and they had enough time to ensure they completed the cleaning that was required. We saw these were stored securely. Laundry systems were in place to minimise the risks from infection wherever practical.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Medicines were administered safely. For example, when people needed their medicines at certain time frames before or after food. This was confirmed by people we spoke with, for example one person told us, “They are very good at giving medication, very regular and organised.”

Medicines had been kept securely. However, not all expected actions had been taken to ensure they were stored at safe temperatures. For example, when the fridge used to store medicines had been recorded as being outside of the recommended temperature range, staff had not always taken the actions recommended by leaders to complete checks and confirm a satisfactory temperature was maintained. There was no evidence to show when the fridge temperature had gone out of range appropriate checks were completed, no risk assessment had been completed to ascertain if the medicines were still safe to use or whether they needed to be disposed of and a new prescription issued.