The Four Seasons Trust Limited - 33 Abbotswood

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 requires improvement. At this assessment the rating has remained 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 and staffing.

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 have a consistently proactive or positive culture of safety based on openness, learning, and timely action. Safety concerns were not always investigated thoroughly or acted upon promptly, and opportunities to learn from incidents were missed. As a result, known risks were not consistently mitigated, increasing the risk of avoidable harm to people.

For example, on 11 March a person sustained a minor injury during a seizure in their bedroom. Although the registered manager recognised that action was required to reduce the risk of recurrence, no steps had been taken to implement control measures. When we revisited the service on 24 March, the risk remained unaddressed. This demonstrated a failure to take timely and effective action to reduce a known and foreseeable risk, leaving the person exposed to further harm.

Incidents and accidents were recorded; however, these records did not include analysis, reflective review, or consideration of underlying causes or emerging themes. There was no evidence that incident information was being used to systematically identify learning, implement improvements, or prevent reoccurrence. This limited the provider’s ability to recognise patterns of risk and to embed safer practice.

Although records showed that Duty of Candour had been applied following incidents, including appropriate notification of relevant authorities and relatives and the provision of apologies, the registered manager was unable to explain what Duty of Candour meant. This raised concerns that compliance was not underpinned by sufficient understanding or embedded within a strong culture of transparency and learning.

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 told us the staff were available if they needed support. Relatives stated they were informed when their family members required support or treatment from different agencies.

The staff team and managers told us they worked well with other professionals to ensure continuity of care. Healthcare professionals had a good working relationship with the service and communication was good.

People who used the service had lived there for many years. The staff knew them well and understood their needs and wishes.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People said they felt safe from harm and abuse. One person told us, “Yes we do feel very safe. If I did not feel safe, I would call the police on 999.”

Although the registered manager told us staff received safeguarding training and regular refresher training, they were unable to provide training records to evidence this during the inspection. Records seen after the inspection demonstrated that 3 out of 7 staff had received safeguarding training recently, 1 staff had started but not completed the course, and 3 had not started.The registered manager told us they would ensure all staff would receive this training going forward.

Staff were aware of their responsibility to safeguard people and who to contact in the event of any safeguarding concerns. One staff member told us, “We do know how to protect people. I would talk to the manager if I had any concerns.”

The provider was proactive in raising safeguarding concerns with the local authority and CQC. They worked with the relevant professionals to investigate concerns when incidents occurred. For example, where a medicines error had been identified, the registered manager told us the staff member had been expected to undertake further training and had their competencies assessed before being allowed to administer medicines to people. The registered manager told us, “The staff all know what safeguarding is and have the information they need.”

The provider understood their responsibilities under the Mental Capacity Act 2005 to ensure that Deprivation of Liberty safeguards (DoLS) applications were submitted as required. At the time of our inspection, nobody was being deprived of their liberty unlawfully.

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

At our last inspection, we found that some risk assessments did not always describe the risks accurately or clearly described what action staff should take to minimise risks. At this inspection, we found this was still a concern.

Although risk to people’s safety, health and wellbeing was documented, not all areas of identified risk had been assessed and mitigated. For example, in relation to the incident mentioned previously in this report, we found this had been documented and appropriate agencies informed, but no further action had been taken to prevent the risk of re-occurrence. The registered manager acknowledged they should have acted promptly and showed us evidence later they had ordered padding for the person’s headboard to protect them from injury. However, the delay in doing this meant there was a risk another incident could have happened in the 2 weeks where no action had been taken. Furthermore, following the incident, the provider had failed to put in place a risk assessment.

People were supported to take positive risks. For example, one person was supported to manage their own medicines with staff supervision, and this had raised the person’s confidence and self-esteem. Whilst staff were supporting the person to mitigate the risks associated with this, the provider had not completed a robust risk assessment to ensure all risks had been identified and mitigated.

Despite these concerns, we saw there were systems in place to protect a person from harm in relation to their condition. For example, ensuring they wore a helmet when out in the community, a monitor in place to alert staff in the event of a seizure, and close monitoring by staff.

Care plans contained detailed information about people’s medical conditions, signs to indicate they were becoming unwell and what actions to take. For example, some people were living with chronic conditions managed by medicines. Care plans provided examples of signs and symptoms to look out for, to help ensure staff would be able to identify a person was becoming unwell.

The provider had processes in place to detect and control potential risks in the environment. However, the ‘Home risk assessment’ was last reviewed in 2023. The registered manager showed us an electronic risk assessment dated January 2025. This was not signed as read and reviewed by the staff. The registered manager told us they usually reviewed this and printed a copy for staff to read and sign, but this had not been done since 2023. This meant there was a risk staff were not consistently aware of environmental risks and the measures in place to manage them.

People were supported in an environment that met their needs. People’s bedrooms were personalised and decorated to their individual taste. The provider had undertaken some refurbishment to areas of the home, such as the kitchen and a person’s bedroom. They were planning to continue working on areas requiring decorating and updating.

The home had areas where people could choose to spend their time, and people had access to a garden, which they told us they liked to use.

There were safety checks completed daily or weekly to ensure safe systems were in place. These included water temperatures, fire safety checks and kitchen equipment. The registered manager told us, “I do all the safety checks or delegate to staff.”

Personal emergency evacuation plans were in place for each person. These contained detailed and pictorial information about each person and the support they required to safely evacuate the building in the event of a fire or other emergency.

The provider did not always make sure there were enough qualified, skilled and experienced staff who received effective support, supervision and development.

Although staff told us they received training, the training matrix we requested indicated some staff had not received training at all or the training was out of date. For example, only one staff member had completed training in first aid, 3 out of 7 staff had completed medicines training and 1 staff member’s training had expired in 2022. Only 2 out of 7 staff had completed food hygiene training, and only 3 out of 7 staff had completed safeguarding training. Furthermore, despite providing care to people with a learning disability and/or autism, most staff had not completed training in these subjects. In most other subjects, staff had not received or completed training. The registered manager was unable to show us evidence of the contrary. This meant there was a risk that people were supported by untrained staff which placed them at risk of avoidable harm.

The registered manager told us they ensured some training was done face to face such as safeguarding, medicines and positive behaviour. However, we did not see evidence of this.

Newly recruited staff received an induction which included a welcome and introduction to the service and people who lived there. The registered manager told us, “Before staff start working at the service, they are expected to undertake training in epilepsy paid for by the company. This includes a real example of what can happen when a person has a seizure and what to do. For example, I talk to the staff about this daily.”

People felt there was enough staff to meet their needs, and said there was always someone around if they needed support.

The provider carried out checks on the suitability of staff before they started working at the service. Systems in place included checks on new staff’s identity, eligibility to work in the United Kingdom and Disclosure and Barring Service (DBS) checks. DBS checks provide information including details about convictions and cautions held on the Police National Computer. This information helps employers make safer recruitment decisions.

Staff told us they were happy working at the home and felt supported and listened to. They said they received training that equipped them to do their job well and care for people who used the service.

Although the provider told us they assessed and managed the risk of infection, they did not always carry out audits to ensure high standards of cleanliness, and when they did, these were not always recorded. The audits we saw were out of date and irregular. This meant we could not be sure action would be taken if any concerns were identified.

People told us they felt safe from the risk of infection because the premises and equipment were kept clean and hygienic. However, a relative told us there were times when they had concerns about the general cleanliness and condition of the house and had raised this with the management.

During our 2 visits, we found the home was kept clean, although untidy in places. Support staff had access to appropriate protective personal equipment (PPE) when supporting people to help protect them from cross infection. The provider employed a cleaning person to ensure the care staff spent their time with the people they supported.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. At our last inspection, we found concerns in relation to the storage of medicines. At this inspection, the provider had made the necessary improvements in this area.

Staff told us they received medicines administration training and had their competencies assessed regularly to ensure they kept up their knowledge and skills. However, evidence of this was not available. This meant we could not be sure staff were suitably trained to administer medicines to people. However, we did not find any concerns in relation to the management or administration of medicines.

Medicines were stored securely in each person’s bedroom and at appropriate temperatures. There was an adequate stock of prescribed medicines. Medicines administration records were completed and signed correctly.

Some people were prescribed medicines to be administered on a when-required basis. We found the protocols in place for these medicines to be administered were detailed and person-centred.

Some people were prescribed epilepsy emergency medicines to be given in the event of a prolonged seizure. Guidance was in place for these.

Our observations and records we checked showed that people were having their medicines administered as prescribed.

There was a medicines policy in place. There was a process in place to report and investigate medicines errors and incidents. Managers carried out medicines audits to identify gaps and make improvements.