Abbeyfield Residential Care Home - The Grove

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 changed to requires 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.

We found breaches in the following regulations:

Regulations 12(1), (2) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Safe care and treatment

The provider failed to have robust systems in place to demonstrate medicines were effectively managed. Whilst risks to people’s personal safety had been assessed care plans did not always record the care needed to minimise these risks.

Regulations 18 (1), (2) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Staffing

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. The service used a matrix to monitor staff training. It was unclear from the training matrix which staff were up to date with their training. Staff we spoke with did not always feel supported by management.

This service scored 44 (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 did not always have a proactive and positive culture of safety based on openness and honesty. Staff felt management did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice. Some staff we spoke with did not feel that the culture of the service was one of openness and transparency. Staff did not always feel their concerns were always listened to and acted upon. Comments included, “Communication could be improved between us and management. Management is not really visible and that has an impact on the service” and “Management are not always approachable and available to seek guidance from.” Lessons were not always learned from accidents, incidents or complaints. Records we viewed did not evidence that accidents or incidents had been reviewed to ensure lessons were learned and changes to care made where necessary. Concerns or complaints were not always recorded. For example, one staff informed us of a complaint raised by one of the people living at the service. There were no records of these concerns being raised or the actions taken. The manager did verify with staff that these concerns had been brought to their attention but not reported to management or recorded.

The provider worked with people and healthcare partners to establish and maintain systems of care. They made sure there was continuity of care, including when people moved between different services. There was evidence in people’s care plans that assessments had been completed prior to them accessing the service. Information regarding people’s care needs was available should a person be admitted to hospital from the service. This ensured there was continuity of care when people moved between services. The service worked alongside health and social care professionals to meet people’s needs. Referrals were in place for services such as speech and language therapy (SALT), occupational therapy and GPs.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately. There was not effective systems, processes and practices in place to ensure people were protected from abuse and harm. The previous registered manager had not raised the necessary safeguarding alerts as required by their registration. For example, we reviewed safeguarding records and could not find evidence of safeguarding alerts for people who it was determined were being made to get up early in the morning by staff. Staff we spoke with confirmed this practice had taken place and had been reported to the previous registered manager. Staff did not always understand their responsibilities for raising safeguarding concerns outside of the organisation. Whilst staff received training in safeguarding and were committed to keeping people safe, they had not raised the concerns discussed during inspection with any outside agencies such as the local authority safeguarding team. People and their relatives said they felt the service provided was safe. Comments included, “Yes, I most definitely feel safe here” and “Yes, I do feel safe here. I would know what to do, if I didn't.”

The provider did not always work well with people to understand and manage risks. However, staff did provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Whilst risks to people’s personal safety had been assessed care plans did not always record the care needed to minimise these risks and keep people safe. For example, one person’s skin integrity care plan recorded they had capacity to understand about positional changes but were unable to make those changes themselves. There was no positional plan or records in place to support staff on how to provide appropriate care to minimise the risk of a pressure wound. For another person staff reported to me that they were being left in bed for long periods of time. There was no plan in place about how and when this person should be encouraged to sit out and whilst senior staff I spoke with where able to tell me about the person’s needs, these were not documented in their care plan.

People had personal emergency evacuation plans in place. However, plans did not always contain details of what support was required to evacuate the person safely in the event of an emergency.

The provider did not always detect and control potential risks in the care environment. Checks were completed by the management team which included legionella tests, fire alarm tests and certificates. Whilst there was a health and safety checklist completed monthly in 2024 this did not clearly identify what was being assessed as part of the checks. For example, various headings such as accident analysis and medications where simply ticked each month under the managers health and safety audit. The audit did not include any detail of what checks had been completed and if there were any areas of improvement identified. This meant we could not be assured that potential risks in the care environment had been adequately assessed.

Maintenance and electrical checks were undertaken to ensure they were safe for people that used the service. Servicing of equipment was carried out to ensure it remained fit for purpose.

The service was currently undergoing a programme of renovation and decoration.

People's bedrooms were personalised. People were surrounded by items within their rooms that were important and meaningful to them. This included such items as books, ornaments and photographs. People told us they could spend time in their room if they did not want to join other people in the communal areas.

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. Staff we spoke with did not always feel supported or listened to by senior management. Comments included, “Management is not really visible. Communication could be improved between us and management” and “Management is poor. The home needs a management presence to support staff and ensure they are doing their jobs.” Staff spoke about low morale amongst staff and not working together as a team. Comments included, “Team morale is not good. We are not working as a team. The old staff are resistant to change” and “There are lots of conflict between staff and they don't want to work with each other.” Safe recruitment practices were followed. Permanent staff did raise concerns about the use of agency staff and how they were sometimes not skilled to meet people’s needs. Comments from people using the service and their relatives were mixed. Their comments included, “Some staff are very caring and particularly excellent at their jobs and exceptionally caring. The problems are some agency workers can be difficult to understand and there is often confusion” and “Staff are very caring and supportive. There is always the time and the trouble taken to speak with her and encourage her all they can.” Records we reviewed did not clearly evidence that staff had received up to date training relevant to their role. The service used a matrix to monitor staff training. It was unclear from the training matrix which staff were up to date with their training. Whilst people and relatives spoke positively about the care received, they did feedback about the use of agency staff and the difficulties with communication and understanding.

The provider assessed and managed the risk of infection protection and control. They detected and controlled the risk of it spreading.

Measures were in place to maintain standards of cleanliness and hygiene in the home. For example, there was a cleaning schedule which all housekeeping staff followed to ensure all areas of the home were appropriately cleaned. We found bedrooms and communal areas were clean, tidy and free from any unpleasant odours. The service had adequate stocks of personal protective equipment such as gloves and aprons for staff to use to prevent the spread of infection.

The provider did not always make sure medicines were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning the management and administering of their medicines. The provider ensured there were sufficient medicines at the service for people, however some people had medicines available that were no longer prescribed. Some medicines were in the trollies but not recorded on the medicines administration charts. This meant we could not be assured records reflected what medicines people received. Further work was needed to ensure records were accurate and complete. Oversight and monitoring of controlled drugs was not robust. For most people whose records we reviewed, the documentation to support the use of as and when required medicines and medicines with a variable dose was not up to date or accurate. We could not be assured topical medicines were being applied as prescribed. Most people who were prescribed creams did not have body maps in place to guide staff in where to apply the creams, and reference to creams was not documented in care plans or on medicines administration records. Records to show that creams had been applied were not always available or completed. For people who were prescribed thickeners (medicine added to drinks to prevent chocking) care plans did not provide staff with information on how to safely use the thickener. In addition, records regarding fluid intake did not always reflect that thickener was being used. The treatment room was clean and tidy, but we could not be assured medicines which required storage in a fridge were fit for purpose. We asked the provider to review this. Audits completed in October and November 2024 identified areas for improvement. Although actions were documented to address the issues, themes continued to be a concern during this inspection. December 2024 audits were not available. We could not therefore be assured governance arrangements for medicines kept people safe.