Abbey Grange 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 assessment we rated this key question good. 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.

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 and positive culture of safety based on openness and honesty. However, staff listened to concerns about safety and investigated and reported safety events. The management team had just started to complete lessons learnt exercises to ensure trends and patterns were identified and improvements to practice took place. This process required embedding into practice.

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 provider had a process to ensure people transferring to another service, such as hospital, had all relevant information shared. This included their life history, medical condition, current medication and care plan summary.

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. The provider had a policy and procedure in place to manage safeguarding concerns. Staff completed training in safeguarding people from the risk of abuse and knew what action to take if they suspected abuse. One staff member said, “If I had concerns of abuse, I would discuss this with [registered manager]. I have full confidence that [registered manager] would take the appropriate actions. If they didn’t, I would contact the area manager to discuss my concerns.”

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA, whether appropriate legal authorisations were in place, when needed, to deprive a person of their liberty, and whether any conditions relating to those authorisations were being met. The registered manager maintained a record of DoLS and people’s care plans included information about mental capacity. Staff were knowledgeable about MCA. One staff member said, “I have had training on Mental Capacity Act. This is something that impacts all aspects of care. This can take the form of getting consent to deliver care. Residents do have the right to make unwise decisions.”

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. Risks associated with people’s care were mainly identified but action was not always taken to mitigate risks. Care plans were quite detailed; however, we found instances where staff did not follow them. For example, care plans gave a good description of how to support people to transfer using a hoist, giving detail of the size of sling to use and loop configuration. However, we observed staff using different slings and not following people’s care plans. Some people required their food and fluid intake to be monitored due to the risk of weight loss. Food charts did not give the amount of food served or amount eaten and did not describe how food was fortified. Following our inspection the management team took swift action to review care plans and observe care delivery to ensure people were supported safely. Care plans were updated to include photos of the slings to be used and clear guidance for staff

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. During the inspection we identified some concerns in relation to environmental safety. For example, radiator covers throughout the home were damaged, some bedroom doors were wedged open which posed a fire risk, and large items of furniture were not always secured to the walls. The management team had previously identified some of these issues and were working to complete actions on their environmental action plan. However, some concerns required prompt action to ensure safety. Following our inspection the registered manager confirmed dates when issues would be addressed and reassured us that urgent matters had been resolved.

The provider did not always make sure there were enough qualified, skilled and experienced staff. Staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs. The provider had a dependency tool which helped them identify the number of staff required each day. However, staff were not always deployed or led effectively which impacted on the support people received. The management team were aware of these concerns and were looking at staff deployment and leadership to improve the experience for people. The provider had a recruitment policy which supported them to recruit suitable staff. Staff told us they received appropriate training and support and felt supervision sessions were valuable. One staff member said, “We have supervisions and appraisals, where we can discuss goals or any concerns we might have. These are followed up on in the next appraisal.”

The provider did not always assess or manage the risk of infection. We carried out a tour of the home and identified several areas which required cleaning. For example, kitchenette cupboards required cleaning, a fridge seal was broken, and storerooms needed to be organised to allow effective cleaning, and shower flooring was coming away from the wall creating a gap where debris was gathering. We raised these issues with the registered manager who took immediate action to address some concerns and following the inspection confirmed action had been taken to address the other concerns. However, cleaning schedules and processes required reviewing and embedding into practice to ensure the service remains clean.

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. People received their medicines form staff who were appropriately training and competent to administer them safely. Staff received training in the safe administration of medicines and were knowledgeable about the management of medicines. People who were prescribed medicines on an ‘as and when’ required basis, often referred to as PRN, had protocols in place to ensure safe and appropriate administration.