Abbey Rose

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 remained good. This meant people were safe and protected from avoidable harm.

This service scored 66 (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.

Openness and transparency about safety was actively encouraged and embedded in the service. Staff described how any safety concerns are shared with them. Comments made included, “They are discussed during handovers, meetings, and through incident reporting. The service regularly reviews incidents to improve care and prevent recurrence.” And “The culture is open, respectful, and supportive.” This created a learning culture where staff were encouraged to reflect on events and understand how improvements could be made.

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.

Prior to admission into the home, an initial assessment was completed. Where possible, this was completed face to face to ensure the provider could meet the persons’ assessed needs. Relatives told us they, and their relative were encouraged to visit the home to see if Abbey Rose was a suitable home.

The provider ensured people were supported to receive appropriate health care as needed. Should staff be concerned about people they would contact relevant healthcare professionals.

Staff supported people to attend medical appointments and shared information when they were admitted to hospital. This helped ensure the person received care that was in line with their wishes and preferences.

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 were protected from the risk of abuse and avoidable harm. All staff received regular safeguarding training. Staff described how they would recognise and report safeguarding concerns. They understood the provider’s safeguarding and speaking-up policies. Staff told us, “I would feel confident reporting any concerns and believe they would be dealt with appropriately.”

Daily handover meetings were used to share information from one staff shift to another. This ensured any new risks or safeguarding issues were communicated to staff promptly.

The provider had a robust process in place to ensure concerns were reported to the local authority without delay. The senior care co-ordinator had oversight of all concerns raised, this allowed them to identify patterns and monitor outcomes.

Where people required any deprivation of liberty in order to keep them safe, the provider had applied for lawful authorisation from the local authority. Information about deprivation of liberty safeguards (DoLS) was clearly recorded in people’s care records. The care manager maintained a record of all DoLS applications which alerted them to when a person’s DoLS was due for renewal. We saw best interest decisions were recorded where decisions were made about restrictive practices. For example, we saw a person’s mental capacity was assessed and a best interest meeting was held with their family which considered the least restrictive options to ensure their safety.

Staff understood people’s capacity to make decisions about their care and support and used people’s preferred method of communication to act according to their wishes.

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.

Risks to people had been assessed and steps taken to mitigate risks to people’s safety. These were completed in partnership with people whenever possible to ensure they understood what steps to take to minimise risks and maintain their independence. Changes to the person or the risks were noted and reassessed as needed and residual risks minimised as far as possible.

People had personal emergency evacuation plans (PEEPs) in place, which were easy to locate. PEEPs provide staff and emergency service personnel with critical information on the evacuation needs of each person in the event of an emergency.

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.

Staff told us, “Some areas of the home would benefit from maintenance, particularly replacing or repairing worn furniture, to provide a more comfortable and pleasant environment for residents.”

The passenger lift had been out of order since 23 July 2026 and was waiting for a part in order to be fixed. There was no risk assessment in place to identify the negative impact this would have on people not being able to access the ground floor. The provider confirmed the lift had been fixed and was working on 3 August 2026.

We identified that not all wardrobes or tall furniture had been fixed to the wall to prevent toppling. This had not been identified as a risk of potential harm to people. The senior care manager contacted the maintenance team who completed the necessary work the following day.

We saw records to show equipment was serviced and checks were undertaken on electrical items, moving and handling and fire safety equipment to ensure that it was safe to use. Health and safety checks had been undertaken to ensure safe management of utilities, food hygiene and hazardous substances.

The premises and garden were free of obstacles and hazards, and we observed people moving safely and independently with or without staff assistance around the care home. We saw staff support people with equipment in a safe way.

Relatives told us their relative was happy with the home and their bedrooms, which they were able to personalise.

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.

We received mixed feedback regarding staffing levels. Comments received included "They would probably benefit from there being more staff available." And "There are enough staff about when I visit." And “They are always very busy, but they always ask if we would like a hot drink or squash.” Staff told us, “Most of the time there are enough staff to meet people’s needs. There are busy periods, the team works together to ensure residents receive person-centred care.” We observed staff were friendly and knew people well; however, there were limited interactions with people, particularly during lunchtime due to the staffing levels.

The care manager told us a dependency tool was used to determine staffing levels based on people's individual needs and that staffing levels were appropriate. However, the lift had been out of order since 23 July 2026, and staff were required to use the stairs to provide support, medicines and meals to people who could not access the ground floor due to their mobility needs and therefore remained in their bedrooms.

The provider had not identified this event as requiring an increase in staffing levels. As a result, people who would ordinarily have used the lift to access communal areas remained in their bedrooms and had limited contact with staff beyond the delivery of personal care. Staff did not provide any stimulating or engaging contact with people on the first floor. People's main meal on the first floor was served approximately 40 minutes after it had been served downstairs in the dining area. We observed several people on the first floor pushing food around their plates and appearing not to enjoy their meal. We did not see any staff identify the food may have been cold, or any staff available to encourage or support people.

Staff had been recruited safely with all pre-employment checks completed prior to them starting. Staff retention was good, ensuring consistency for people. Staff told us they were supported in their role with good access to training and supervision. Comments made included, “The induction, training, and ongoing support have been excellent, helping me develop my knowledge and skills.” And “Staff are encouraged to complete additional training and qualifications, and I have regular supervision and appraisals where I receive helpful feedback”.

Records showed staff received regular supervision and appraisals. Staff told us, “I receive regular supervision and support from seniors and care manager.”

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 service employed a dedicated domestic team to ensure the home was clean. A relative told us, “The home is always clean and tidy.”We saw cleaning schedules were completed, and regular audits were carried out.

Regular checks and audits were completed to ensure staff followed the provider’s infection prevention and control (IPC) policies to keep people safe and the service clean. Personal protective equipment (PPE) was available, we observed staff used and disposed of PPE appropriately. Relatives told us they saw staff wearing PPE “When I have seen them doing personal care they do.”

Staff received training in IPC and had a good understanding of the correct procedures to be followed. They told us, “I know which type of PPE is needed for different things. I have received training and we receive updates in staff meetings.”

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

There were suitable systems in place for the storage, ordering, administration and disposal of medicines. Medicines Administration Records (MARs) showed people received medicines as prescribed. Effective arrangements were in place for administering topical medicines like creams and emollients. These were supported by body maps and clear application instructions for staff.

However, fridge temperature records were not completed accurately and in accordance with the providers policy, and staff were unable to demonstrate appropriate temperature monitoring processes. This meant the provider could not be assured that refrigerated medicines had been stored within the recommended temperature range.

Specific medicines were stored appropriately and records were well maintained. However, the service did not undertake regular balance checks for these medicines. While not a legal requirement, routine balance checks are considered good practice and support the early identification of discrepancies.

One person with a history of recent falls who was prescribed an anticoagulant medicine did not have an anticoagulant risk assessment in place. This meant the risks associated with falls and anticoagulant treatment had not been formally considered, potentially delaying recognition and response to bleeding complications following a fall.

Protocols were available for all ‘when required’ (PRN) medicines reviewed. However, for medicines prescribed with a variable dose, care plans and protocols did not always provide sufficient person-centred guidance on how and when doses should be adjusted within the prescribed range. Examples included prescribed laxatives, where records did not clearly describe the circumstances or symptoms that should inform dose variation. This increased the risk of inconsistent medicines administration.

Staff told us, “I administer medication, and my competency assessments are completed regularly as required.” And “I am confident in administering medication and understand the importance of following safe procedures”.