Abbot Care 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 people were protected from abuse and avoidable harm. At our last assessment we rated this key requires improvement.

At this assessment the rating has remained requires improvement.

The service was in breach of legal regulation in relation to people’s safe care and treatment.

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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events.

Whilst lessons were learnt to continually identify and embed good practice. More work was needed to ensure all processes including ABC documents were included withing their overall analysis. An ABC chart (Antecedent, Behaviour, Consequence) is a tool used to understand and monitor incidents of distress or emotional reactions suggest you use something like emotional reaction. It helps staff identify patterns, triggers and effective interventions so care can be adapted to reduce future incidents.

A variety of meetings were held including clinical meetings to view and discuss accidents and incidents. Staff told us this information was shared with them to promote learning.

People did not always experience coordinated care and support through effective systems and pathways.

Care records did not consistently provide staff with accurate, up-to-date information to support safe decision-making and continuity of care. We found inconsistencies in care plans relating to the management of people's swallowing difficulties, seizure risks, skin integrity, mobility and distressed reaction support.

Records did not always explain why people were receiving care in bed. This meant it was not always clear whether these arrangements reflected people's current needs, risks or personal preferences

However, staff and managers had established positive links with external organisations and healthcare professionals, which promoted effective information sharing and partnership working. Referrals to external health and social care professionals were made in a timely manner.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve this. Staff focused on improving people's lives while protecting their right to live safely, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns promptly and appropriately.

People and relatives told us they felt safe at the service. One person told us, “I am here because I had a fall. I haven’t fallen since I came here 6 months ago.” Another person said, “It’s alright here, I am happy.” A relative said, “Definitely safe and meets their needs. They have their own room and have adapted it to suit [family member], and staff come along and check on them.”

Staff were knowledgeable about recognising and responding to abuse and described the appropriate actions they would take to keep people safe. One staff member said, “If I suspected that a resident was being abused, neglected or was at risk of harm, I would take it seriously and report my concern immediately to the nurse in charge, senior member of staff or manager, following the safeguarding procedures. I understand that safeguarding concerns can involve physical, emotional, sexual or financial abuse, neglect, discrimination or inappropriate treatment. I would also make sure that any concern was recorded and reported through the correct procedure. If I felt that my concern had not been dealt with appropriately, I would escalate it to the appropriate person or authority. We are encouraged to speak up if we see poor care or anything that could put a resident at risk. The priority is always the safety and wellbeing of the resident.”

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 found mental capacity assessments and care plans were in place where appropriate. The service had oversight of deprivations of liberty applications and authorisations.

The provider did not always work effectively with people to understand, assess and manage risks to their health, safety and wellbeing.

Care plans and risk assessments were not always accurate, complete or reflective of people's current needs, which increased the risk of staff relying on incorrect information when providing care. For example, one person's eating and drinking care plan stated they required a pureed diet due to dental pain and an inability to chew; however, they were observed eating chips and biscuits. This indicated the care plan had not been reviewed to reflect the person's current needs and preferences.

Similar inconsistencies were identified in records relating to skin integrity, seizure management, swallowing risk, hydration, mobility and wheelchair-related risks, meaning people could not be assured risks were consistently identified, reviewed and managed. While some sections of care records contained accurate and up-to-date information, other sections had not been updated to reflect changes in people's needs and circumstances.

Although audits had identified some inconsistencies within care plans, they had not identified all of the concerns found during our review of 14 care plans during the inspection. Following our feedback, the provider responded proactively. They implemented a system of allocating named staff members responsibility for reviewing care plans to ensure inconsistencies were identified, addressed and monitored.

ABC charts were not consistently used to identify triggers, patterns or the effectiveness of interventions. Care plans contained person-centred strategies to reduce distress; however, records did not always demonstrate whether these had been implemented or reviewed following incidents. This meant the provider could not be assured behavioural risks were being managed consistently or learning was being used to reduce future incidents.

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

People lived in an environment that was generally clean, maintained and suitable for their needs. Equipment and environmental risks were managed through established processes. The provider was working on risks to wheelchair users as stated in the risk section of this report.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. However, observations and feedback from relatives indicated improvements were needed,

There were sufficient numbers of staff available to support people safely during the inspection. Staff received training relevant to their roles and understood their responsibilities in relation to safeguarding and people's safety. However, there were periods during the inspection when some people spent extended periods of time in communal areas with limited meaningful interaction from staff. Opportunities to engage people in activities, conversations and social stimulation were not always maximised. People and relatives gave us mixed feedback about staffing. Positive comments included, “There are usually enough carers around,” and “It seems to be pretty well-balanced. Always someone around. The staff work together well as a team and want to help people.” However, others added, “Short of staff and even worse when 2 staff are assisting someone. Evening is worse,” and “I would think that there could be more staff and to chat to them and have a talk to [family member] and that doesn’t happen.”

Despite this, people and relatives generally spoke positively about staff, describing them as caring and approachable. However, improvements were needed to ensure all people consistently received meaningful engagement and opportunities for social interaction throughout the day.

Staff were positive about staffing levels at the service. A staff member told us, “I think the staffing levels are appropriate. On the floor where I work, we normally have 4 carers and 1 nurse, and we have enough staff available to meet the needs of the residents.” Another staff member said, “I feel we have a good staff level at the home. Maintaining good staffing levels is very important to ensure safe, effective and person centred care while also supporting staff wellbeing. Inadequate staffing levels significantly compromise individual safety and care quality.”  

Staff were recruited safely. The provider carried out appropriate checks on new staff before they started work. These included verifying their identity and eligibility to work in the UK, obtaining at least 2 references from previous employers, and completing Disclosure and Barring Service (DBS) checks. The DBS helps employers make safer recruitment decisions and prevents unsuitable people from working with vulnerable people. Registered nurses have a unique registration number known as a PIN, which provides assurance to the provider they are fit to practise.

The provider assessed and managed the risk of infection. They identified and controlled the risk of infections spreading and shared concerns with appropriate agencies promptly. Minor issues identified during the first day of the inspection were addressed promptly.

Staff demonstrated an understanding of infection prevention and control procedures and had received relevant training to support them in their roles. People and relatives did not raise any concerns regarding the cleanliness of the environment. One relative said, “It is clean. I know that if I have any issues, I can go and tell someone.”

We reviewed infection control records and found environmental and equipment checks were generally completed as required. Refrigerator temperature records were up to date, and actions had been identified and taken where equipment issues had occurred.

The provider had systems in place for the ordering, storage, administration and disposal of medicines. Medicines were stored securely.

Overall, medicines were managed safely. Staff responsible for administering medicines had received appropriate training and competency assessments. People's Medicines Administration Records (MARs) were generally completed appropriately, and there was evidence of regular medicines audits being undertaken.

However, medicine stock checks completed during the inspection identified minor discrepancies between physical stock levels and recorded balances.

During observations in people's bedrooms, we found topical creams and lotions were not always stored securely. This reduced assurance all medicines and medicinal products were being managed in accordance with best practice. However, the provider responded immediately to our feedback, and lockable storage boxes had been put in place by the second day of the inspection.