Abbeydale 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 inspection we rated this key question requires improvement. At this inspection the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 72 (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. Lessons were learnt to continually identify and embed good practice.

Staff told us the home felt like a “big family” and said they were supported by a visible and approachable manager. They described an open culture where they could discuss mistakes and learning without fear. Monthly audits across infection prevention control [IPC], dining, kitchen checks, medicines and health and safety were consistently completed and demonstrated actions being identified and implemented. For example, concerns raised about laundry processes and unlabelled clothing in October were addressed and had improved by December.

Staff also received feedback from Multi-Disciplinary Teams [MDT] partners. Professionals described the service as proactive, consistent and responsive, with strong handovers and willingness to learn. Lessons were shared through staff meetings, supervision and daily use of electronic systems and eMAR. Staff told us leaders encouraged continuous improvement and checked dashboards to ensure actions were completed. This helped embed a culture focused on learning and safe care.

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.

People experienced safe and coordinated care. Handover systems were effective, with staff using electronic devices to record real‑time information. MDT input was strong, with regular meetings involving GPs, community matrons, pharmacy and social workers. Professionals reported the home was proactive and prevented avoidable hospital admissions.

Staff monitored incidents monthly and took action such as increasing 1:1 support where needed. Transitions of care were generally well managed, and staff escalated issues with discharge processes appropriately when information or equipment was missing. Care plans were usually clear and guided staff on actions following falls, pressure‑care needs and swallowing risks.

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.

Staff understood their responsibilities and told us they felt confident reporting concerns. Training compliance in safeguarding was high, and staff could explain what constituted abuse and how they would escalate concerns.

Records showed safeguarding referrals were made appropriately, including when people experienced unwitnessed falls or when discharge processes created risks. Staff demonstrated knowledge of people who may be more vulnerable, including people living with dementia or those receiving 1:1 support.

Relatives told us they felt people were safe, and professionals gave strong assurances about risk management and vigilance from staff. There were no themes of institutional practice, and staff described a culture where people’s rights were respected.

Staff supported people to make choices and respected unwise decisions where appropriate. DoLS applications had been submitted as required.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff understood people’s preferences and routines well; this was seen during observations where people appeared relaxed and supported. Care plans for people who lacked capacity included examples of how to offer choices and maintain control over daily life.

Risk assessments were in place and reflected individual needs, including diet textures, falls risks, mobility and pressure care. Staff were knowledgeable about people’s risks and gave examples of how they adapted support. Records showed actions such as increased monitoring and referrals to SALT or dietitians were made when concerns arose.

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.

The environment was clean, tidy and significantly improved following refurbishment. People told us the home was homely and comfortable. Infection‑control audits showed high compliance, and cleaning schedules were followed with issues acted on promptly.

However, some areas still required improvement and these were being addressed by the provider. A cracked toilet basin and issues with equipment such as a broken Bain Marie were noted and awaiting completion. Personal Evacuation Plans [PEEP]s were in place.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

There were enough staff with the right skills and experience to meet people’s needs. Staffing levels were appropriate on the days of inspection, with several 1:1 staff in place to support people at high risk of falls or with distressed behaviours. Staff were visible, responsive and knew people well.

Recruitment files sampled were well organised and showed DBS checks, references and induction records were completed. Staff spoke positively about training and said they felt confident in their roles. The training matrix showed very high compliance, with most staff at or near 100% for mandatory courses.

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, odour‑free and well maintained. IPC audits scored highly, and staff were observed using PPE safely and washing hands at appropriate times. Colour‑coded cleaning equipment was used correctly, and chemicals were stored securely.

Communal spaces and bedrooms were tidy and personalised, and staff followed laundry procedures, including correct segregation of items. Although a small number of issues were identified through routine audits such as carpets needing hoovering or shower chairs requiring cleaning these were resolved immediately and signed off.

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. Stock balances of sampled medicines matched the eMAR system, and controlled‑drug checks were accurate. Room and fridge temperatures were monitored daily, and medicines were stored securely.

Staff were knowledgeable and escalated issues promptly with the pharmacy when needed. PRN medicines were used appropriately and not over‑relied upon, and we advised the provider to ensure PRN protocols were always fully detailed within the records. This action has been completed.

People received their medicines as prescribed. Staff had completed medicines‑management training and competency assessments.