Abington Park View 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 means we looked for evidence that people were protected from abuse and avoidable harm.
At our last assessment, this key question was rated good. At this assessment, it has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety.
Risks were not always identified or managed effectively, and environmental safety checks were inconsistent. Some areas of the home required better oversight to ensure potential hazards were addressed promptly. The provider was in breach of the legal regulation in relation to safe care and treatment.

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.

The provider maintained an open and transparent approach to safety. Staff said they felt confident raising concerns, knowing that managers would listen and act on them. Incidents were reviewed, and learning was shared through meetings and supervision. Records of learning outcomes were being strengthened to show how improvements were embedded in practice. Management and staff worked with healthcare professionals, such as doctors and social workers, to ensure people received appropriate care. Processes for investigating, analysing, and responding to accidents, incidents, complaints, and safeguarding alerts were in place. Staff understood their responsibility to report all accidents and incidents. One relative stated, “Staff are on it quickly when something happens”.

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.

Systems were in place to ensure people’s needs and relevant information were communicated when they moved between services. This included referrals to healthcare professionals, managing new admissions, and hospital admissions and discharges. Management and staff were well-informed about people’s needs, risks, and the support required. Each person had a hospital pack prepared within the electronic system to support safe and timely information sharing in the event of hospital admission. This allowed essential care details to be transferred quickly and accurately to external professionals, reducing the risk of delays or omissions. Staff knew where to access the hospital pack when needed. This helped to provide continuity of care, supporting the safe and effective management of people’s health and wellbeing.

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 with the staff and the care provided. A person said, “I do feel safe because they are all very good to me.” Staff received safeguarding training and understood their responsibility to keep people safe and how to report concerns. Safeguarding information and policies were accessible to all staff, and management ensured these were kept up to date.

Management and staff understood local safeguarding arrangements and worked in partnership with other agencies when concerns were raised. Information on how to report safeguarding concerns was available to staff, people, their relatives, and visitors to the service. All safeguarding concerns were recorded in detail, investigated appropriately, and learning was shared with staff where needed. People’s health and well-being were closely monitored following any concerns or incidents to ensure they remained safe and supported.

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.

The provider worked with people to manage risks, particularly around falls prevention and skin integrity. However, there were inconsistencies in how some risks were assessed, documented, and monitored in practice. For example, care plans contained contradictory information, one person’s mobility plan stated they required full assistance for all transfers and were unable to move independently, while their skin care plan recorded that they could move themselves. This created confusion for staff and increased the potential for inconsistent care.

Some care plans lacked clear and consistent instructions on repositioning intervals and comfort checks, and a few charts were not fully completed. During the assessment, the manager took immediate action to address this, reviewing and updating care plans and reminding staff to ensure all records were accurately completed.

We also observed a sensor mat placed slightly away from a person’s bed, meaning it would not have activated if they attempted to get up. No staff had noticed this until it was raised. The manager rectified this immediately and reminded staff to check sensor placements as part of their routine safety checks.

While prompt action was taken and improvements were observed, these inconsistencies in risk assessment and recording meant people were not always fully protected from avoidable harm.

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.

Safety checks were in place for fire systems, hoists, and other equipment. However, some environmental risks had not been fully identified or addressed at the time of the assessment. Not all wardrobes were secured to the wall, which posed a risk of injury if they became unstable. The kitchen door was found propped open on more than one occasion using a chair or trolley, which compromised fire safety procedures.

A sharps bin was also found stored on top of a wardrobe in one of the bedrooms. This was immediately removed, and the registered manager confirmed this would not recur. One of the platform lifts had been out of order for a week, hence the medication trolley was temporarily kept in the dining room and not secured to the wall. Although the trolley remained locked at all times, it was not in its usual designated area.

Personal Emergency Evacuation Plans (PEEPs) were in place for everyone living in the home; however, these did not include creation or review dates. The registered manager took immediate action to update all PEEPs during the assessment.

While environmental risks were addressed promptly once identified, these issues indicated that oversight of environmental safety checks was not always consistent.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

There were enough staff on duty to meet people’s needs, and staff described teamwork as good. Interactions observed between staff and people were kind and respectful. However, recruitment processes were not safe or robust, and this placed people at potential risk of harm.

Several staff files did not contain full employment references. One file contained only a single reference, while another included a reference from a personal email address. In one case, a reference was provided by a manager who had known the employee for only three months, despite their CV showing they had been employed at that organisation since December 2024.

Some staff had started work before Disclosure and Barring Service (DBS) checks had been returned. The risk assessments completed to support these decisions were not sufficiently detailed and did not include evidence that they had been discussed with the staff concerned. One staff file noted a DBS in the update service, but there was no record of an update check having been completed at the time of recruitment.

For international staff, passport copies were not retained on file. Instead, a form was used stating “original passport seen.” In one of the files the induction forms were incomplete, meaning there was limited evidence to confirm that induction processes had been followed consistently.

Recruitment practices did not meet CQC and employment regulation requirements. These shortfalls demonstrated weak oversight of recruitment and induction systems. The registered manager immediately began reviewing all staff files and implemented a more robust and safer recruitment system to ensure compliance with regulatory standards going forward.

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.

Overall cleanliness and hygiene were good throughout the service. Cleaning records were up to date, and the home had a pleasant smell in all areas. Staff followed appropriate infection prevention and control procedures, including the correct use of personal protective equipment (PPE). People’s rooms were kept clean, and bathrooms contained soap, paper towels, and appropriate bins for waste.

Food was stored hygienically, with items labelled and within date. Kitchen areas, including ovens, shelving, and serving trolleys, were clean and well maintained. However, glove boxes had been left open in communal areas, which posed an infection control risk. These were removed immediately once identified.

There was no formal documentation template to record deep cleaning, which the registered manager agreed to develop and implement. The manager also confirmed that deep cleaning schedules would be monitored going forward to ensure consistent oversight.

The service maintained good infection prevention practices overall, and any shortfalls identified were addressed promptly.

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 stored safely and administered in line with national guidance. Staff had received training in medicines management, and competency checks were carried out regularly. Medication Administration Records (MARs) were accurate, and PRN (as required) protocols were clear and detailed. However, some protocols did not include creation or review dates. The registered manager confirmed these were being updated, and several had already been completed during the assessment.

Medicines with a limited shelf life, such as liquids and creams, were dated when opened. MAR charts were completed appropriately, and PRN records included reasons for administration and the effectiveness of the medicine given. Monthly audits were completed, and controlled drugs were checked weekly to ensure accuracy and compliance.

The registered manager took immediate action to strengthen medicines governance. All topical creams were dated on opening, and PRN protocols were reviewed to include creation and review dates. These prompt actions improved the consistency and safety of medicines management across the service.