Abbott House - Oundle

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 59 (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 culture of safety, where there had been incidents and accidents the provider had not always taken enough action to reduce immediate or short term risks to people.

The service had experienced incidents where people became distressed due to interactions with other people using the service in communal areas. We discussed this with the management team at the service and were told that there were no contractual agreements to provide staff supervision of communal areas. This meant that risks to people had continued as staff were not always in the vicinity to intervene and support. The provider was seeking support with identifying an alternative home for people whose needs could no longer be met safely.

There was a system in place to record accidents and incidents and monitor for trends and patterns. Accidents and incidents were recorded and reported appropriately to safeguarding and the Care Quality Commission (CQC) when needed.

The service had experienced some unwitnessed falls. The provider had taken measures to reduce risk such as further staff training or supervision and providing people with falls monitoring equipment. A relative told us, “[Relative] has a sensor mat now as they had some falls when on their own”. A falls analysis was completed monthly to identify trends and patterns, and people were referred to falls prevention professionals where needed.

The provider worked with people and healthcare partners to continuity of care, including when people moved between different services.

There was a system in place to ensure smooth transition between services. For example, if people were transferred into emergency care there was a system for sharing information on people’s health conditions, medication and care needs.

There was evidence of monitoring people’s pathway and recording and reporting changes in need that meant they may need an alternative service. The provider worked collaboratively with healthcare partners to facilitate the reassessment of people's needs and support a smooth transition to alternative services when the home could no longer meet those needs.

The provider did not always ensure people were safe. They did not always protect people’s right to live in safety, free from bullying, harassment, abuse or avoidable harm.

Where people had expressed distress towards others, the provider shared concerns quickly and appropriately with other healthcare professionals and sought additional funding for enhanced 1:1 support.

For example, we saw that the provider had shared information with the local authority and made requests for interim funding to increase support for people and help keep other people and staff safe. However, the provider had not deployed additional staff to the area for closer monitoring to ensure people and staff safety whilst an alternative service was sought or staff funding increased. The provider increased the level of observations but records did not consistently evidence that the observations took place. Most people told us they felt safe as staff were kind and looked after them well, but some people and relatives had concerns with other people entering their rooms. The risks to people were addressed by the end of the assessment.

Staff were trained and demonstrated a good understanding of safeguarding and when they should raise concerns and who to.

Deprivation of liberty safeguards (DoLS) had been applied for where needed. Where conditions were in place on a DoLS these had been adhered to.

The provider did not always manage risks. Staff did not always provide care to meet people’s planned care needs to keep them safe.

People had individualised risk assessments and associated care plans in place that were updated regularly. Positive risk taking was supported. We saw that where people were able and wanted to they left the home to visit family or enjoy the community. People were accessing the homes gardens independently to take part in gardening activities or just enjoying the outdoors. However, risks to people had not always been mitigated as planned care was not always delivered. For example, where a person was at risk of pressure sores they were not always repositioned as planned. Where a person was experiencing difficulty with orientation and their care plan stated they required glasses we observed them not to be wearing them at each site visit. Where another person had a specific routine detailed and established with family to prevent the risk of oral damage there was no evidence that this was being followed.

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

The provider had systems and processes in place monitored by a competent maintenance manager to ensure regular safety checks of the environment were completed. For example, regular checks of water and electrical safety. Repairs to the building were carried out promptly and where improvements were identified via safety audits these were actioned promptly. A person told us, “It’s a safe place to live as they’ll sort out any issues”. We found some areas of increased risk in the environment. For example, vulnerable people had some unsupervised access to toasters and kettles containing boiled water. We shared our findings with the provider who acted promptly and ensured the risks were mitigated by day 2 of site visits.

The provider did not always make sure there were enough staff. They did not always work together well to provide safe care that met people’s individual needs.

Staff were recruited safely in line with regulatory requirements. Staff completed an induction and mandatory training prior to working independently with people. Training was regularly updated and competency checks completed to highlight where additional training and support were required. Post incident supervision and additional training was provided where needed.

The provider used individualised dependency tools to support staffing numbers and deployment across shifts. However, we were not assured these were effective with consistently ensuring there were enough staff, with evenings on 1 floor being a particular concern. We found a number of people required 2 to 1 support for their evening/bedtime routine which meant people with high needs who display anxieties and distress, sometimes towards others, were left unsupervised in communal areas. Inspectors observed an altercation in an unsupervised communal area that increased the risk of potential harm. Inspectors observed on several occasions people in other people’s rooms to which we alerted staff for support. A person told us they found it frightening when a person entered their room and whilst they could summon help others in the home were more vulnerable.

People told us that there wasn’t always enough staff to meet their needs with bedtime and nighttime being a particular concern. A person told us, “They’re beginning to struggle a bit and have the minimum on. There’s a lot of waiting. I need help with [a personal care task]. At certain times you may have to wait, especially at bedtimes and mornings, they can’t be everywhere”.

Staff told us that there was not always enough of them. One staff member told us that sickness could not always be covered which added pressure to an already challenged staff team. They also told us that some personal care needs, such as oral care, were occasionally missed. In addition, when care was provided, staff told us didn’t always have time to record in care notes. Another staff member told us they were worried about staffing numbers at night. We have reported further on these concerns in well-led.

People were supported by a regular team of staff that knew people well and understood their needs. The provider had an internal bank of staff to cover sickness and holidays and had a regular core of agency staff.

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 home was visibly clean and odour free. A person told us, “My room is kept gorgeous. The laundry service is very good, mine often comes back the same day”. Staff had received training in infection control and had access to personal protective equipment (PPE). There was guidance displayed around the home to support staff with the prevention of infection, such as handwashing guidance and the safe use of colour coded equipment.

Where infection outbreaks had occurred, the provider followed relevant policies and procedures to minimise risks to people and visitors and reported these appropriately to the relevant authorities.

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.

Medicines were managed safely. Where any missed or late medications had been identified the provider had acted appropriately following their internal policy and procedure including appropriate reporting and gave refresher training for staff support and prevention of future incidents.

We observed a senior member of staff deliver medication in line with good practice guidance whilst ensuring people’s privacy and dignity. Medicines were stored safely and securely in locked trolleys and a medication room with checks of room and fridge temperatures in place.

Where people expressed a wish to manage some of their medication independently this was assessed and agreed where it was safe to do so.