Abbeydale - Derby

A learning culture had not always been effectively operated to help prevent incidents recurring.

Care plans and risk assessments were not always up to date or reflected how risks to people’s health should be managed. Information in care plans was sometimes contradictory and people’s involvement in on-going reviews of their care plans and risk assessments was not always evident.

Medicines had been administered safely however, improvements were needed to how some medicines were stored and how the effectiveness of some medicines were recorded.

Whilst a variety of food choices was available for people, not everyone was provided with food choices that met their needs. Monitoring of people’s care was not always effective.

The principles of the Mental Capacity Act 2005 (MCA) had not always been considered or followed.

Some aspects of leadership were not yet fully effective as the governance systems were not yet fully embedded to identify where the service needed to improve and how to mitigate risks. Records were not always accurate or complete.

However, staff understood the principles of safeguarding and what actions to take to help protect people from abuse. Recruitment checks were completed before staff started to work at the care home to help ensure they were suitable to work there. Staff provided timely care to people.

There were safety measures in place to help ensure the care home premises was safe. There was a regular cleaning schedule in place to ensure the care home was kept clean.

Staff worked well together and treated people with kindness and respect. They worked to promote people’s independence. Staff told us they felt well-supported by the leaders at the service and were confident to speak up if they thought anything was wrong.

Staff provided a range of activities for people and worked to engage them in interests and maintain their connection to the local community.

Staff worked to provide person-centred care to people however, inaccuracies in people’s care plans meant this was not always consistent.

Staff had built links and worked in partnership with other health and social care services to help people access the care they needed. Staff understood any communication needs people had.

We found three breaches of the regulations relating to safe care and treatment, consent and good governance.

We have asked the provider for an action plan in response to the concerns found at this assessment.