Abberdale Ltd t/a Abberdale House

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

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 Required 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 62 (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 reported safety concerns in accordance with the providers’ policies and procedures. Accidents and incidents were recorded and reviewed monthly, demonstrating that the provider had oversight processes in place. Learning from incidents was identified and shared with staff to support reflective practice and inform service improvement.

Staff were kept informed of incidents and any changes to people’s care and support needs through a structured handover and timely updates. The registered manager told us they record falls directly onto each person’s individual profile page on the online care plan system. This approach enabled staff to make quick updates and ensured relevant information was readily available. Incidents were reported to relevant external bodies, including the local authority and the Care Quality Commission, on time and in line with regulatory requirements.

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.

There was a structured system in place to ensure preadmission assessments were completed before people moved into the home. The registered manager told us they visited people in their previous homes prior to admission, using this approach to gather information from the individual, their family, and relevant history, with an aim of completing a picture of the person’s needs as much as possible before they arrived at the service. This approach demonstrated an intention to ensure admissions were planned and staff had access to meaningful information to support people safely from the onset.

People and their relatives told us that they had been involved in care planning at the point of admission. Family members told us they generally felt involved at the pre-admission stage. However, some people told us they could not recall having seen their care plan, suggesting that ongoing involvement was not always consistent. Relatives told us they were kept informed about their loved one’s care. One person told us, “They ask me regularly if I’m happy.” And a family member told us, “They text me to ask if the care plan is ok or if I’ve any concerns.”

Individuals were encouraged to personalise their own space by bringing in their familiar belongings, including photographs, ornaments and personal items. This supported people to maintain a sense of identity and helps them to feel like their own room rather than an unfamiliar environment. The provider demonstrated an understanding of the importance of familiar surroundings to people, particularly people living with dementia, demonstrating a person-centred ethos within the service.

The registered manager had effective working relationships with a range of external professionals. We received positive feedback from professionals who have worked alongside the service. One professional told us, “I have developed a good, open relationship.”

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.

Systems were in place to protect people from the risk of harm, abuse and discrimination. The provider had taken a proactive and visible step approach to safeguarding, displaying a dedicated safeguarding board within the service, which clearly highlighted the different types of abuse, their definitions and the signs and indicators that staff should be alert to. This demonstrated a commitment to ensuring safeguarding awareness was embedded into the culture of the home and was readily accessible to all staff. Staff received safeguarding training, providing them with knowledge and skills to recognise and respond to concerns appropriately. The combination of these approaches indicated the provider had taken a layered approach to safeguarding, supporting staff to maintain awareness and vigilance on a day-to-day basis.

Staff demonstrated a clear understanding of the importance of safeguarding and were confident in recognising signs of abuse or neglect. They were able to articulate how they would report concerns both internally through the provider's own processes and externally to relevant statutory authorities, demonstrating an awareness that safeguarding responsibilities extend beyond the organisation. A staff member told us, “I would report any concerns to the management team and feel assured they would be investigated.” This level of knowledge indicated safeguarding training had been effectively embedded into practice, and staff felt empowered to act if they had concerns. This is fundamental where people are protected and where a culture of openness and accountability is maintained.

The provider had recently introduced a compliance officer to the service, whose role included oversight in training and compliance across a range of areas. Safeguarding was indicated as a key area of focus on their agenda. This was a positive development and indicated a commitment to ongoing improvements in this area.

Safeguarding referrals were made in a timely manner and the provider worked well with the local authority.

The provider did not consistently ensure that systems were in place to involve people in understanding and managing risks associated with their care. As a result, staff did not always deliver care in a way that upheld safety, supported individuals appropriately, or reflected what was important to them.

Positive Behaviour Support plans (PBS) were in place for people who could become distressed or anxious. However, we found these did not follow PBS best practice framework guidance. PBS is an evidence-based framework that looks beyond behaviour itself to understand its function, identifying triggers, unmet needs and what may be communicating. We found plans in place predominantly described behaviours, rather than analysing the reasons behind them, and the language used labelled behaviour in a way that was reductive rather than seeking to understand their purpose. This meant staff were not always equipped with the information needed to anticipate, prevent, or de-escalate situations. When this feedback was shared, it was received positively. The provider confirmed they were being supported by external agencies to redevelop their PBS plans in line with the PBS principles, which demonstrated a commitment to improving outcomes for people.

The provider demonstrated an understanding of risk management, recognising people had the right to take positive risks and make decisions about their lives, whilst ensuring appropriate measures were in place to keep them safe. One staff member told us, “Everyone has the right to make an unwise choice.”

Staff demonstrated a good understanding of the people they were supporting and were able to describe individual risks confidently and in detail. Knowledge of people’s needs were not solely reliant on written documents but was embedded in the culture and practice of the 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.

A first-floor toilet window was found to have no restrictions in place and it fully opened. Whilst the risk was partially mitigated by the fact it was not fully in use by people using the service, the absence of a window restrictor does not meet the required safety standards. People’s bedrooms were fitted with window restrictors, which was a positive measure; however, some window handles were found to be broken. The provider acted immediately to ensure repairs were made promptly.

During our inspection, we found some other environmental concerns. For example, a radiator cover was coming loose from the wall, and others were deteriorating. In addition, 1 wardrobes was not safely secured. This posed a potential risk of injury to people living in the service, indicating regular environmental checks were not consistently identifying concerns.

Regular electrical safety checks and fire risk assessments were completed to support a safe and compliant environment.

Each person had a personalised emergency evacuation plan (PEEPS) in place, which provided clear guidance to staff on how to support individuals safely in the event of a fire. PEEPs identified the level of support each person required to evacuate, the equipment to be used, each person’s ability to follow, their capacity and their ability to mobilise. This demonstrates the provider had considered people’s individual needs in an emergency. However, further work was needed to develop PEEPs to include how best to support people from an emotional and behavioural perspective during an evacuation.

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.

The provider ensured that sufficient numbers of qualified, skilled and experienced staff were deployed to meet the needs of people living at the service. Staff received effective support through regular supervision and opportunities for development, enabling them to maintain and build on their knowledge and skills. Staff were observed to work well together as part of a team.

Staffing levels were good across all days of the inspection. The provider did not use agency staff; instead maintained their own bank staff, which supported continuity and familiarisation for people using the service, ensuring that people were supported by staff who knew them well.

Safe recruitment processes were in place. Records confirmed that Disclosure and Barring Service (DBS) checks before employment. Staff files contained certificates of training and references from previous employers, evidence that appropriate pre-employment checks had been carried out.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

PPE was observed to be worn appropriately throughout the inspection. Staff demonstrated an understanding of how to dispose of PPE correctly, reducing the risk of cross-contamination. A hand-washing facility was available at the entrance of the building, supporting good infection prevention and control practices.

Monthly IPC audits were in place, and the provider advised that deep cleaning of rooms were carried out daily, demonstrating that systems had been established to maintain cleanliness and reduce the risk of infection. However, during our inspection, we found some bedrooms were not clean. This was raised with the registered manager, and immediate action was taken. Whilst the provider advised the housekeeper had not yet completed their rounds at the time of inspection this meant that potential risks of infection had not been identified and addressed in a timely way.

Some relatives raised concerns about their loved ones’ clothing, suggesting that laundry processes were not always ensuring that people’s personal items were returned to them. The registered manager confirmed they were aware of the ongoing laundry concerns and were actively taking steps to address the issues.

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 stored safely. Regular medication audits were completed both for individual people and across the service. Only staff who had completed medicines training and had been assessed as competent were authorised to administer medicines to people. However, at this inspection, we identified that there were no clear protocols for PRN (as required) medicines in place. This meant there was limited information available for staff on when PRN medication should be administered, what symptoms to look for, or when to escalate concerns. Although charts to support the monitoring of people’s distress were being completed, staff were not recording the outcome of medicines administered to reduce distress, and records were not always made promptly. This limited the provider’s ability to monitor the effectiveness and inform future decisions. The provider took immediate action to rectify this, which was a positive response and demonstrated willingness to address concerns without delay.

The provider was also operating across 2 systems, which resulted in information not being consistently captured. 1 system indicated medicines were out of stock; however, this was not accurate, highlighting the risks of discrepancies between systems.

We found no body maps in place to record the application of topical creams. The absence of body maps in this context meant that there was no accurate record of evidence that topical medicines were being applied correctly and consistently in line with the prescribers' instructions.

Some people required medicines to be administered covertly (by hiding the medicines in food or drink). Whilst Mental capacity assessments had been completed, records did not always contain the documentation required to demonstrate covert administration had been appropriately authorised in line with the Mental Capacity Act 2005. However, the provider had received written confirmation from the GP regarding how medicines should be administered.

People received medicines as prescribed and at the right time. Staff were observed to be caring and attentive during medicine rounds. Medicines were stored in an organised manner and controlled drugs were stored in line with legislation. There was a system in place to monitor the correct temperature range of fridges. The service had a process in place for monitoring medicine storage and for the safe return of unused medicines.