Abode

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 inadequate. At this assessment the rating has changed to 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 the ways people’s medicines were managed, the environment and the management of safety and risk.

This service scored 50 (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 and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice.

We found significant shortfalls in the safety of the environment and audits were not consistently effective at identifying shortfalls. Audits did not support learning or continuous improvement. They had not always identified if changes were needed to help ensure the safe management of medicines and the safety of facilities.

However, staff we spoke with knew who to report accidents and incidents and could explain why this was important. We saw examples of some lessons learned being shared with staff at team meetings.

Accidents and incidents were reported to the relevant professionals. This meant that people could get the support and treatment they needed.

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.

Staff communicated well with a range of external professionals to ensure people moved between services safely. There was a pre-admission assessment process in place. This included recording people’s needs and preferences. Information about people’s needs was available to staff prior to people moving into the service. This maintained people’s safety.

Referrals were made to healthcare professionals appropriately. If a person needed to go into hospital in an emergency, written information was provided. This helped communicate essential information to staff who may be unfamiliar with the person’s needs. We found these needs were not always peoples current health needs and some aspects of the care plans had not been kept up to date, the provider has now updated these.

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 told us they felt safe. One person said, “I was having problems at home with getting around and my personal care. Here the staff are always willing to help me and that I suppose keeps me safe.” Relatives had mixed reviews on safety and one relative said, “I have no worries about my [relatives] safety. I do think the staff know their job.” And another said, “I don't feel my [relative] or I know the staff well enough, and this may impact on the safety of the residents. If you don't understand the needs and habits of a person, you are caring for, it will impact on their care.”

Deprivation of Liberty Safeguards (DoLS) applications were submitted appropriately. Mental capacity assessments were carried out and discussions were documented. However, we found this was not done consistently and there were gaps in risk assessments for bedrails. This put people at risk of having restrictions in place that were not lawful.

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.

There was not always a balanced and proportionate approach taken to managing risk that respected people’s choices. Details on care plans and risk assessments were not always detailed enough to inform staff of the needs of an individual. For example, there was lack of information in a person’s care plan about when ‘prescribed when required’ (PRN) medication should be given and this was not always closely monitored. Risk assessments were not in place for people at increased risk of bleeding due to prescribed medication and those who had flammable creams. The provider updated these care plans following our visit.

Various environmental risk assessments were in place though audits of the environment did not always identify the risks we found. This meant that people who were independently mobile did not always have risks managed safety in relation to access to outside space.

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

Some aspects of the environment were not safe, and significant improvements were required in this area. For example, a garden gate, which was a fire route exit had no key available for the lock, this posed a risk to all in the property if evacuation was needed. There were sharp objects left in the garden which posed a risk of injury to people. Objects including paint stored in an unsecured smoking area posing a fire risk. The provider told us they now would conduct a daily garden safety check to ensure the environment was safe. We found not all bed rails were included on the bedrails check list so not all were being checked for their safety. This posed the risk that faulty equipment would not be identified and place people at risk of avoidable harm.

We found a broken and loose electrical wire was trapped in one of the fire doors. The interim manager and provider could not confirm the wire was not live. This posed a risk to people’s safety. The provider arranged for an electrician to come and sort this promptly before we left. It was confirmed that the wire was not live. This meant that the door had not been alarmed and posed the risk of people leaving or entering the building unauthorised. Outside surfaces were uneven and the handrail was broken. This posed a falls risk and meant people who were independently mobile were unable to safely access the garden without assistance.

People did not report any concerns with the environment and reported they felt safe, whilst recognising areas for improvement. A relative commented, "Although I think my [relative] is safe enough, I would move my [relative] if I could afford it. There are areas they could do better.” A person told us, "Once I am in my chair in the lounge I am not going to come to much harm and in bed at night that is me settled. So, I suppose I am safe.

We discussed our concerns with the interim manager. Prior to the assessment concluding we received some written assurances that action was being taken to resolve the issues we discussed.

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

The provider had a dependency tool to help assess the number of staff required to support people. People said they didn’t always receive support quickly at busy times and they thought more staff were needed. A person said, “Sometimes I wait a little while for help, but the staff are very busy.” Another person said, “Sometimes they [staff] come and sometimes they take forever.” They went on to say, “I don’t mind, I know they are busy. Staff said, “We need more staff at busy times of the day and, “If one of us is helping someone, one of us is doing personal care, and one is doing medicines, residents must wait. There is not enough of us.” We spoke to the provider about this, and they have implemented more staff at busy periods.

Staff said they had regular supervision and felt supported by the management team. A staff member said “The management team are very good at helping me and if I had any concerns, I would speak to them.”

Staff had received robust induction training, and they had been trained in areas that would provide them with the knowledge to carry out their role. Staff were able to talk to us about the training that they had received and said, “There’s always training to do here.”

Staffing levels at night were being closely monitored to see if the staffing numbers were having any direct impact on peoples care and the time they waited for assistance.

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 clean and tidy. There was a member of staff that cleaned and managed the laundry. People said they were happy with the cleanliness of the home. A person said, “My room is always clean and fresh.” A relative said “[relatives] room is always clean."

Staff were provided with gloves and aprons to use when appropriate. There were cleaning rotas in place and these were effective in maintaining a clean environment with no odours.

There was a sluice room with hand washing facilities and a separate laundry room. The were handwashing guides displayed to encourage effective handwashing.

The kitchen was clean. However, we found not all food was stored safely with some packet food being stored opened without dates of opening recorded. The provider took action to address this.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

Medicines were not always stored in line with the provider’s policy. On two occasions we found the storage area for medicines was not kept secure despite this being reported by inspectors. Areas used to store medicines had the temperature monitored.

Medicines administration records (MAR’s) did not always contain correct and up to date instructions. For one person who had a dose of their medicine changed staff had not recorded this on the MAR chart. For another who received their medicine on specific days of the week this wasn’t documented in the instructions on the chart. We had seen evidence of a previous medicine incident related to this where the person had received the wrong dose.

We found for one person that the MAR chart did not contain their name and had the wrong bedroom number documented. This put people at risk of receiving their medicines incorrectly.

Instructions for medicines to be prescribed when required (PRN) were available but did not always contain all the information staff would need to ensure the medicine could be used safely. Staff did not always document the reason for a medicine being administered or the outcome from its use, which puts people at risk of receiving their medicines in an inappropriate way.

People’s care plans did not always contain the information needed to ensure staff could look after people in a safe way. For example, for 2 people prescribed anti-coagulants there was no care plan in place to inform staff of the risk of bleeding and for people prescribed laxatives there was no information for staff on when these should be used. For people prescribed flammable creams there were not always risk assessments in place.

People were supported to look after and administer their own medicines, and risk assessments had been completed to ensure this was done in a safe way.

Staff had received training to manage medicines and had their competency assessed. It was not clear how effective this process was due to the issues found during the inspection.

Although the service completed their own audits these had not picked up on the concerns found during the inspection. An external audit that was conducted in February 2026 had picked up on some of these issues such as those around PRN medicines however this continued to be a concern at this inspection so we could therefore not be assured the audits and action plans were being followed and were effective.