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

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 changed to good. This meant people were safe and protected from avoidable harm. The provider was previously in breach of the legal regulation in relation to safe care and treatment. nutrition and hydration and staffing. Improvements were found at this assessment, and the provider was no longer in breach of this regulation.

This service scored 63 (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 consistently capture, or review lessons learned from accidents and incidents. The provider did not always routinely analyse events to identify trends or patterns that could reduce future risks. Although staff had systems available to raise concerns and managers responded to these on an individual basis, the provider did not record or evaluate organisational learning from incidents. The provider did not document any formal debriefs following accidents or incidents. One staff member told us, “I’ve have never had a debrief.” However, team meetings provided a platform to discuss with staff, how to report and record if an incident or accident took place.

Conflicting information in people’s care records increased the risk of them receiving incorrect care, particularly when moving between services. For example, 1 person’s care plan stated they did not have a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decision in place. However, their Deprivation of Liberty Safeguards (DoLS) paperwork included a ReSPECT form indicating that a DNACPR had been agreed. This inconsistency created a significant risk that staff might act on inaccurate information during an emergency.

People who may require hospital admission had hospital passports in place. These contained essential information about their health needs, current care requirements and relevant contact details, helping to ensure continuity of care if they attended hospital.

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.

Systems to safeguard people from abuse were effective and understood by staff. A safeguarding adult’s policy was in place to guide practice, and staff had completed safeguarding training. They demonstrated clear knowledge of their responsibility to report any signs of potential abuse. One member of staff told us, “I will report it, tell the senior, who will pass it on to management. Or I tell the manager straight away.”

People and their relatives told us they felt safe living in the home.

The service was working in line with the Mental Capacity Act (MCA). People were only deprived of their liberty when this was in their best interests and legally authorised through the Deprivation of Liberty Safeguards (DoLS). Appropriate DoLS authorisations were in place for people who lacked capacity.

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.
Staff did not consistently follow people’s risk assessments, which placed them at avoidable risk. Although assessments covered key areas such as mobility, nutrition, hydration, personal care and falls, staff did not always apply the guidance in practice.

Daily records and observations showed gaps in required support. For example, 1 person needed prompts to slow down when eating to reduce the risk of choking, but staff did not provide this during the observed mealtime.

The provider had effective systems in place to identify and manage environmental risks, helping to ensure people received safe care. Equipment, facilities and technology were monitored and maintained to support safety.

The registered manager carried out regular checks across the care home to ensure the environment remained safe. However, we identified areas of the care home interior required repair and the provider took prompt action to address these issues. A relative told us, “It’s very clean, but it is in need of lots of repairs.”

Records showed routine monitoring of electrical systems, legionella, water temperatures and fire safety equipment. Personal emergency evacuation plans were stored in an accessible emergency grab bag.

The nominated individual described ongoing investment in the home, including a new roof, an upgraded call-bell system and improvements to the heating system. They also outlined plans to replace people’s bedroom furniture and redecorate the interior of the home.

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.

Safe staffing levels were maintained across the service, ensuring people received timely care. Staff were visible, attentive and responded promptly when people required support.

The provider had safe recruitment procedures in place. Pre-employment checks were completed before staff started work, including enhanced Disclosure and Barring Service (DBS) checks for adults.

Staff had access to a range of training to support them in their roles. The provider assessed staff competencies in key areas such as moving and handling and the administration of medicines, helping to ensure staff had the skills needed to deliver safe care.

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.

The provider had effective infection prevention and control (IPC) measures in place. Monthly IPC audits were completed to monitor compliance and identify any areas for improvement. Staff followed an IPC policy that aligned with current good practice.

Staff had received training in infection prevention and control and used personal protective equipment (PPE) appropriately, such as gloves and aprons during personal care. Staff told us PPE was always available, and they were able to describe the different situations in which PPE should be used.

The provider did not always ensure medicines were managed safely because staff did not consistently follow established procedures.

The service had processes for the safe storage, administration and recording of medicines, but staff did not apply them reliably.

Records showed staff did not complete regular controlled‑drug balance checks in line with national guidance, so we could not be assured controlled drugs were monitored safely. Staff also recorded medicine storage temperatures inconsistently and missed required checks, leaving no assurance that refrigerated medicines were kept within safe ranges.