Roche Abbey 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 that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to 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. Accident and incidents were analysed and trends and patterns identified to mitigate future risks. The management team had commenced some lessons learnt documents to reflect on incidents and used them to improve the service. The manager told us the plan was to carry out more lessons learnt exercises in the future.

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. Documents were in place to pass on information to relevant others such as the hospital staff, were clear and detailed how people preferred to be supported and gave information about their medical needs. Details of people’s prescribed medicines were also part of the emergency pack. People and relatives told us they had access to healthcare professionals and care plans were updated to include their advice.

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. The management team kept a record of safeguarding concerns and could evidence that processes had been followed and concerns were reported to the appropriate bodies. Staff received training in safeguarding and knew what actions to take to protect people from harm. One staff member said, “If I suspect abuse, I will notify management immediately and complete an incident report. I am more than confident that our management would take the appropriate action.”

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 associated with people’s care were identified and actions were taken to mitigate risks. Risk assessments were detailed and explained how to support people safely. People told us staff managed their care well. One person said, “I feel safe because I trust them [staff]. I have all the equipment that I need.” Staff told us they knew how to manage risks safely. One staff member said, “We conduct risk assessments on a regular basis and implement appropriate measures to keep people safe.”

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. We identified some areas which required attention. For example, 2 windows were without restrictors and 2 fire doors were worn. The provider took appropriate actions to address these issues, but they had not been identified prior to our assessment. People’s care plans included information about maintaining a safe environment. For example, communal areas were kept free from clutter to ensure people’s risk of falls were mitigated. Personal emergency evacuation plans were in place to ensure people could evacuate to a safe place in an emergency.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. However, they did not always work together well. The provider had a tool in place to calculate the number of staff required to meet people’s needs Staff were available in line with this process. However, staff required to be deployed effectively. For example, throughout our assessment we identified 1 lounge without staff presence and without social stimulation. Some relatives told us there were not enough staff around. The management team were made aware of these issues and have implemented daily checks to ensure staff are deployed effectively. Staff told us they worked with enough staff to meet people’s needs. One staff member said, “Yes, we have enough time to carry out our tasks and I feel that our staffing levels are adequate.” The provider had a recruitment system which assisted them in the safe recruitment of staff. The provider completed pre-employment checks such as references and Disclosure and Barring Service (DBS) checks. DBS checks provide information including details about convictions and cautions held on the Police National Computer. This information helps employers make safer recruitment decisions.

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 predominantly clean and tidy; however, we found some areas had not been deep cleaned. Since our site visit the manager had taken action to ensure cleaning schedules were updated and a full deep cleaning schedule had been put in place. This system required embedding in to practice to ensure it was effective. We saw staff followed safe infection prevention and control processes.

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. People received their medicines as prescribed from staff who were trained and competent in the safe administration of medicines. We saw medicines were stored safely and checks were carried out regularly to ensure stock balances of medicines were correct. Some people were prescribed medicines on an ‘as and when’ required bases, often referred to as PRN. Protocols were in place to ensure PRN medicines were administered safely. Staff received training in medicine management and the management team ensured staff competency checks were completed. One staff member said, “Our competencies are checked by management to ensure we have understood training and guidance given to us. This is done by observing and questioning us whilst we are working.”