Leiston Old Abbey Residential 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 good. At this inspection the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to staffing and safe care and treatment.

This service scored 38 (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 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. Lessons were not learnt to continually identify and embed good practice.

Although we found when things went wrong lessons learned were documented, we were not assured this system was embedded and used effectively to prevent similar issues happening.

The staff meeting minutes from June 2025 showed how staff were updated in the requirements of their role following a safeguarding incident. However, staff told us staff meetings were not often held to ensure messages were shared with the team effectively. A staff member told us that whilst lessons learned were shared electronically and written, there was a lack of face to face guidance and actions taken when staff had not followed the guidance. Where staff were advised of actions they needed to take, in for example, electronic messages, there was a lack of follow up and monitoring by the provider and registered manager to ensure the improvements were being sustained and embedded in practice.

We were not assured lessons were always learned and acted on, for example, during the first inspection visit, we noted unclean bed linen, this was addressed by the second day and fed back to the provider and registered manager. However, following this, we received feedback from a relative where they had noted unclean and ripped bedding. This demonstrated despite this being a known shortfall, it had continued after our visits.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

The registered manager told us assessments were undertaken prior to people using the service, with the input of people, their representatives and commissioners.

The registered manager told us important information was shared with other services, such as if a person was admitted to hospital. However, during our assessment we found care plans were generic in some parts, not kept updated and held contradictions. Therefore, we were not assured information shared between services was always current.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

Staff spoken with told us they understood their roles and responsibilities in identifying and reporting safeguarding concerns. However, not all staff working in the service received this training. In addition, the provider and registered manager were not able to tell us at what point of starting to work in the service staff were required to undertake training in this area. This placed people at risk of harm, as staff may not always understand how to identify and report abuse.

Where required, applications Deprivation of Liberty Safeguards applications had been made to the appropriate professionals in line with the Mental Capacity Act 2005. The registered manager maintained a document which showed when DoLS applications had been made, when they had been approved and when they required updating. However, people’s care plans did not always demonstrate when DoLS had been approved, what restrictions were in place and why.

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.

Staff were not always able to tell us about the care people received, or their needs, which was a risk of people receiving unsafe and inappropriate care. We asked 2 staff members if people used a hoist to mobilise, one did not know and another said they did not. However, care records and the registered manager told us some people did use a hoist to mobilise.

Care records were not always up to date and held contradictions. For example, one person’s records stated they could walk with the use of a frame and also they could no longer walk. Another person’s records stated they preferred two pillows, but also, they were not to be provided with pillows due to risks. Guidance was not always provided to staff relating to the risk of falls, reference was made to assessments of a test, but it was not clear when this was or what it entailed. There were gaps in records of when a person required support to reposition to prevent pressure ulcers developing and/or deteriorating. This person’s records were not clear on what pressure injuries the person currently had. This placed people at risk of harm.

There was little evidence in care records which demonstrated people and their representatives, where appropriate, had been supported to understand risks and involved in the planning of how they were mitigated.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

There were systems in place to make checks on equipment used and the environment to reduce risks. This included fire safety checks and drills and systems to reduce the risks of legionella bacteria in water system. The maintenance and gardening staff understood their roles and responsibilities and kept updated with any tasks required to reduce risks in the environment. A communication book was in place to allow other staff to record any hazards or repairs required, so the maintenance team could address them.

However, we identified some risks in the environment which had not been assessed as a risk by the provider. A person’s wardrobe in their bedroom, although it had been attached to the wall to prevent it falling on them, had a suitcase was on top which was a risk of it falling off onto a person. There was a tall set of drawers, which was not attached to the wall, due to the height of the drawers, there was a risk of them falling forward if the drawers were open.

There was a small area at the side of the service with a glass sloped roof, which was cracked, and there was chicken wire against one of the vertical windows. The provider told us this was used to grow, for example, tomatoes, which people had helped staff do. However, we were concerned this was open on our first visit and a risk if people accessed this area. On our second day this was locked to reduce access.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

There were two staff who worked during the night, we were concerned if an incident happened which required two staff, there would be no staff available to support other people. The registered manager told us there was always staff who could get to the service quickly.

The tool used to support the provider to calculate the numbers of staff required along with people’s assessed dependency needs did not consider the layout of the building, or the support people required for activities. Only support with personal care and meals for the majority of people were taken into account. There were no activities staff working in the service, the registered manager told us all staff working in the service supported people with activities, as well as their other duties.

A staff member told us they felt staff were run off their feet and often breaks were missed or late. Another staff member said sometimes domestic staff were called on to support the care staff, leaving less than the planned domestic staff.

There was a recruitment policy in place, however, this was not always being followed. For example, the policy stated two references must be sought, one staff member’s recruitment file had two references but from the same person. Four staff files reviewed held no interview notes, record of probationary meetings or checks, previous training, evidence of the care certificate, and no authentication of references. Staff identification was not always signed to show originals had been seen.

The registered manager told us all new staff were required to undertaken two shadow shifts with experienced staff which was on the staffing rota, additional shadowing could be undertaken if needed. There was no record in staff files of the shadow shifts, what was covered and if there was any further learning needs identified. The provider and registered manager could not tell us the timescales for new staff to undertake their training as part of their induction. There were significant gaps in staff training. Staff told us they received training online, but some felt they and colleagues would benefit from more face to face training.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading.

During the first visit to the service, we found several areas of concern relating to infection control processes. The floors in the laundry areas were unclean, a washing machine that was in use had a dark substance inside the door on the rubber area and drying machines were unclean. This was addressed immediately with the washing machine being thrown out and the dryers and floors cleaned. The provider told us staff had previously been advised about keeping the laundry clean, however, the issue continued.

On our first visit, we saw stained sheets on people’s beds. On our second visit, clean bedding was on people’s beds. However, we received additional feedback from a relative following our visits, “The state of [family member’s] bedding was disgusting. The sheet was ripped and dirty.” Therefore, we were not assured, despite us pointing out about the unclean bedding seen during our visits, the issue continued.

The cupboard where Personal Protective Equipment (PPE) was stored was not hygienic, there were blankets, a hairdryer and a used hair brush, and a box of masks were open with one hanging out. A bottle of hand wash liquid in a bathroom required handling to pour out the liquid was a risk of cross infection. A jug in a shared bathroom, had a brown substance inside, this was cleaned by our second visit. We asked the registered manager what the jug was used for as we were concerned about communal use which was a risk of cross contamination, they told us all jugs had been removed previously, so were unclear why the jug was in the bathroom and what it was used for.

There was a smell of urine in the entrance hall to the service on both visits, and on the first visit there were malodours in two areas on the first floor. The registered manager told us they would challenge this as they took pride in ensuring there were no malodours in the service. We received feedback from a relative about the smell of urine they had detected when visiting, “When we do visit sometimes the home smells of urine… Toilet really dirty on an occasion.”

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.

The provider was in the process of changing their system from paper based to electronic. Staff who were responsible for supporting people with their medicines had received training and their competency assessed.

Medicines were stored securely in the service and there were systems in place for the ordering and disposal of medicines. We found medicines to be taken orally were managed safely and people received them as prescribed. People received their medicines which were in a patch form, however, records did not always indicate where on the body the patches were placed to ensure this was rotated to reduce skin damage and to ensure they were effective.

Where people were prescribed creams and lotions to be administered, for example for use to reduce the risks of skin injury, the daily records did not show these were always administered as prescribed. The registered manager told us the new electronic system would improve how the administration of creams were recorded.