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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last inspection we rated this key question requires improvement.The provider was previously in breach of the legal regulation in relation to safe care and treatment. Improvements were found at this assessment and the provider was no longer in breach of this regulation.

At this inspection the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 69 (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 had a positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety incidents. Lessons were learnt to continually identify and embed good practice in the home. The management team and staff recognised the importance of learning lessons and continuous improvement to ensure people received care and support that was safe and effective. Staff told us they had opportunities to drive improvements and learnt from incidents which occurred

People and their relatives had opportunities to feedback their views about the service and quality of the care they received. The manager and senior managers had oversight of accidents and incidents that occurred in the home. They identified and addressed trends and patterns that were emerging. We viewed examples of lessons learnt following incidents which occurred within the home. For example, making sure staff were vigilant and contacted health professionals if there were medicine issues, and completed hourly checks and body maps if people were at risk of developing marks or pressure ulcers.

Reflective meetings were held with staff to give opportunities to discuss development needs and encourage improvement in practice. The provider had processes in place to investigate and report safety events. Records showed staff followed processes when reporting incidents and made sure people were kept safe. Staff could confidently tell us how they would report and record incidents or accidents, such as those involving people coming to harm.

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.

The management team worked with professionals and partner agencies to ensure there was continuity of care for people, including when they moved between different services. When people were placed in the home, their needs were assessed and reviewed to ensure they were suited to the environment and living with other people.Staff worked alongside other social care and health organisations to ensure people received appropriate care. There was regular contact with local authority, social workers, and doctors. Staff told us they knew how to contact the local GP surgeries and pharmacies and told us of collaborative work they undertook.

People were supported to maintain their health attend appointments both inside and outside of the service. People's care records showed referrals had been made to healthcare professionals where concerns had been identified. The management team worked hard to ensure continuity of care for people when they were discharged from hospital or moved into the home from their local community. When people were supported to go to hospital, hospital passports were used, and these were currently being updated. Passports supplied hospital staff with vital information about people and their health. This helped support people when transitioning to other services through the care pathway.

The provider had taken active steps to ensure there was an open culture. There was evidence that concerns could be raised safely, poor or unsafe practice was identified and challenged.

People told us they felt safe and comments from people included, “I I am safe; I have no concerns and I feel safe here. A relative said, “I yes, I do think [family member] is safe and they are on a DoLs (Deprivation of Liberty Safeguards).” People were protected from the risk of abuse and their rights were upheld. The provider had a safeguarding procedure so that concerns could be reported to the appropriate safeguarding authorities immediately. Staff and the manager understood how to protect people from the risk of abuse and received training in safeguarding people. A staff member said, “I know how to identify abuse and I have had full training. I would report things like physical abuse or financial abuse.”

Records showed concerns were logged, reported, and monitored to show what actions were taken and the outcomes from each case following safeguarding investigations. We noted a recent incident that took place involving a person choking and this was being investigated by local safeguarding teams. The provider had reviewed the incident, procedures, processes and staff understanding and had noted what actions needed to be taken in future to prevent it happening again. This showed the provider had suitable systems in place to respond to safeguarding concerns.

The provider worked with people to understand and manage risks by thinking holistically. They provided 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 in May 2024, we found some people’s care and risk management plans did not always set out sufficiently how to mitigate risks to promote their safety.

At this inspection, we found improvements had been made and risks to people were assessed more effectively. People were involved with assessments and reviews about the level of support they needed. Risks related to their care such as nutrition, mobility and medicines were assessed to determine the severity of each risk. A risk management plan was included to help reduce the likelihood of people coming to harm.Specific risks such as those for smoking, choking, diabetes and managing emotional distress were also assessed and plans were in place to mitigate them. The provider had sought best practice guidance to follow so that risks were identified and assessed to ensure people were able to maintain their independence and dignity.

Staff worked with people to understand and manage risks which enabled the staff to deliver care that met people’s needs. People told us staff supported them to avoid harm coming to them. Relatives felt staff were well trained and knew their family member’s risks and needs. A relative said, “[Family member] is safe because they get good care.” Other relatives also felt staff used safe techniques when moving and transferring their family members. A relative told us, “We see the carers hoist [family member] from the wheelchair to the lounge chair. They are attentive and don’t rush and we’re really happy with it." Another relative told us, “There are always two people who hoist [family member] into their chair.”

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

At our last inspection, we found the provider had not always managed risks to people’s safety and wellbeing by appropriately maintaining the premises at all times. Some people were also living in rooms that were not always clean and had damaged furniture and missing curtains.

At this inspection we found significant improvements to the environment throughout the home. People’s rooms were tidy and well decorated, with fixtures and fittings in place. However, we found a large window in a person’s room had jammed and was not able to open to allow fresh air into the room. We alerted the manager who reported it to the maintenance team. They then fixed the window later in the day.The premises and garden were free of obstacles and hazards, and we observed people moving safely and independently with or without staff assistance around the care home. We saw staff support people with equipment in a safe way.

At our last inspection we were not assured the home had adequate fire safety systems in place. This included suitable places for people or staff to smoke and extinguish cigarettes. The provider had since installed a smoking shelter in the garden which was clearly signed. However, we noticed some damage to the shelter, which we pointed out to the manager. This was repaired shortly after our inspection.

Fire safety and evacuation processes were adequate to ensure people were kept safe and staff understood what action to take in the event of an emergency. Audits of the environment were carried out to maintain a safe home and working space for people and staff. People also told us they were happy with the home and their rooms, which they were able to personalise. Health and safety checks had been undertaken to ensure safe management of utilities, food hygiene, hazardous substances, moving and handling equipment, staff safety and welfare. Gas, electrical and water safety checks were carried out by professionals.

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.The provider had assessed the staffing levels needed in the home both during the day and at night. The manager told us they had recruited new staff since the last inspection to ensure they were able to meet the staff numbers required.

A staff member said, “We have enough staff I think. There is always cover.” People and relatives we spoke with felt the home was adequately staffed and they had no concerns about this. A person said, “There always seems to be enough staff.”

Staff completed mandatory training and an induction in courses such as safeguarding adults, infection control, food and nutrition and equality and diversity. Safe recruitment practices were implemented to ensure staff were appropriately and safely recruited. The manager ensured processes were followed correctly. This included obtaining applicant’s employment history, proof of identification, work permits, references and carrying out criminal record checks with the Disclosure and Barring Service (DBS). Staff told us they were well supported and records showed they received supervision and appraisals for their continuous development.

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.

At our last inspection we noted some areas of the home were not adequately cleaned and odours were apparent. This had improved at this inspection and we found the home to be largely free of odours and domestic staff made sure areas were sanitised, clean, hygienic and fresh.However, some areas of the home did retain an odour due to people’s needs. We reported this to the management team to add to ongoing actions in maintaining a clean, infection-controlled environment. We also had to report an overflowing bathroom sink to the management team, where the tap seemed to have been running for some time. This meant there was risk of unclean water flowing into the corridors.

Staff had sufficient supplies of personal protective equipment (PPE). They received training to help them maintain good standards of infection control. Staff told us they followed procedures for the use and disposal of their PPE. People and relatives also confirmed staff followed safe infection control practices.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. Staff who gave medicines had the relevant knowledge, training and competency that ensured medicines were handled safely. We observed staff giving medicines safely and they were recorded accurately. Risks related to people’s medicines were assessed. Protocols for 'as required' (PRN) medicines such as pain relief medicines were in place. Guidance for people that needed to have their medicines covertly was followed. Medicines were also stored safely at the recommended temperatures. The service used electronic Medication Administration Records (eMAR) which helped staff monitor discrepancies and medicine errors more effectively. Daily and monthly audits were carried out, to identify errors and issues were addressed promptly.

At our last inspection, we found controlled drugs were not always managed safely in line with best practice guidance. We noted improvements at this inspection and saw that records for these medicines were being completed correctly. Staff followed procedures for recording, auditing and administering medicines to people. Staff competency checks were carried out to assess their knowledge, skills and ability to follow safe medicine administration guidance.