CQC report explained · a nursing home
What the CQC found at Abbcross Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Requires improvement
- People were protected from abuse and medicines were generally stored, administered and recorded safely. However, one end-of-life medicine protocol had an incorrect dose, there was no written protocol for homely remedies, and some risk assessments lacked important detail.
- Effective?
- Good
- People's needs were assessed before moving in, staff were trained and supported, and the home worked with health professionals. Inspectors noted that fluid targets were often identical rather than personalised.
- Caring?
- Good
- Staff were kind, patient and respectful. People were supported to make choices, maintain privacy and dignity, and follow their beliefs and preferences.
- Responsive?
- Good
- Care plans were personalised and updated when people's needs changed. Activities were available, but inspectors said the activity programme needed further work to provide more structured and meaningful opportunities.
- Well-led?
- Good
- The home had a clear management structure, positive culture and systems for checking quality. Some audits had identified issues that were still being improved.
What inspectors found, January 2024
Rated Good overall; inspectors found kind, well-managed care, but safety arrangements need improvement.
Inspectors visited without warning on 5 December 2023. They spoke with people, a relative, staff and managers. They observed care and reviewed care plans, medicines records, staff files, training and quality checks.
The home was rated Good overall. Effective, Caring, Responsive and Well-led were all rated Good. People were treated kindly, their choices were respected, staff were trained, and health professionals were involved in their care.
Safe was rated Requires Improvement. Inspectors found incorrect information in one medicine protocol, no written protocol for homely remedies, and some risk assessments that needed more detail. Fluid targets were also not always tailored to people's needs.
The provider was given recommendations to follow best practice. The report says the management team took immediate action after the inspection and that CQC will continue to monitor information about the service.
Kind and respectful care
People described staff as caring and respectful. Inspectors saw staff speaking calmly, meeting personal care needs and helping people eat at their own pace.
“We observed staff chatting with people politely and patiently, using calm and warm tones of voice.” from the report
Personalised support
Care plans recorded people's communication, health, nutrition, personal care preferences and desired outcomes. Staff updated them when needs changed.
“People received person-centred care that met their needs and ensured they had choice and control of how their care was delivered.” from the report
Trained staff and health support
Staff received induction, refresher training and supervision. The home worked with GPs and other health professionals to support people's health.
“The staff and management team worked well with health professionals to ensure people were in the best of health.” from the report
Positive management culture
People, relatives and staff spoke positively about the management team. The home used meetings, surveys and audits to gather views and identify improvements.
“The provider had established a positive culture in the home.” from the report
Incorrect medicine protocol
seriousOne protocol for an anticipatory end-of-life medicine contained a dose higher than the prescribed dose. The medicine was not given, but inspectors said there was a risk of error and harm.
“there was a risk of error and the person receiving more than what had been prescribed.” from the report
Risk assessments needed more detail
needs fixingSome assessments, including those for diabetes and catheter care, did not give staff enough guidance about what to do in specific situations. One pressure sore assessment also needed updating.
“assessments for specific conditions such as diabetes or catheter care lacked some detail.” from the report
Fluid monitoring was not always personalised
needs fixingMost people's fluid targets were set at the same level instead of being based on their individual needs. One person's recorded intake was often below the target and this needed review.
“fluid targets for most people were set at an identical level” from the report
Activities programme needed development
minorActivities such as bingo, arts and crafts and ball games took place. However, inspectors said the programme needed more structured and meaningful activities.
“the activity programme for the home required further work and development” from the report
- 01What changes have you made to the incorrect anticipatory end-of-life medicine protocol, and how do you check that all medicine protocols are accurate?
- 02Where can we see the written protocols for homely remedies, and who checks that they remain suitable for each person?
- 03How have you improved risk assessments for diabetes, catheter care and pressure sore prevention?
- 04How are each person's fluid targets set, monitored and reviewed when their intake is below target?
- 05What new structured and meaningful activities have been added since the inspection?
This was an unannounced inspection that looked at the overall quality of the home, including both the premises and the care provided, and assessed all five key questions. This explanation was written from the published report of 30 January 2024 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, January 2018
Rated Good; inspectors found safe, kind care and said a previous legal problem had been fixed.
This was an unannounced inspection over two days in November 2017. The inspectors observed care, spoke with people, relatives and staff, and checked care records, medicines, recruitment files, staffing records, complaints and quality checks.
All five areas were rated Good: safe, effective, caring, responsive and well-led. Inspectors found enough staff, safe medicines systems, suitable training, kind and respectful care, personalised care plans, activities and good management oversight.
At the previous inspection, the home had breached a regulation about best-interest decisions under the Mental Capacity Act. Inspectors found that this had been corrected. The report also says that lunchtime support had improved since the previous inspection.
Safe medicines
Medicines were given by trained staff who had been assessed as competent. Records, storage and regular audits were found to be in order.
“People's medicines were managed and administered safely.” from the report
Kind and respectful care
People said staff were kind and respectful. Inspectors saw staff supporting people gently and protecting their privacy and dignity.
“We saw that staff supported people in a kind and gentle manner and responded to them in a friendly and patient way.” from the report
Personalised support
Care plans included people's needs, likes and preferences. Staff knew people well and supported them to make choices and remain as independent as possible.
“Staff knew people well and were able to tell us about individual needs, likes and preferences.” from the report
Activities and end-of-life care
The home had a full-time activities worker and offered games, music, outings and celebrations. End-of-life support was provided with input from healthcare professionals.
“A full time activity worker was in post to support this.” from the report
Strong monitoring
Management used audits, meetings, visits and feedback to monitor quality and record follow-up actions.
“Effective systems were in place to assess and monitor the quality of the service and to implement any necessary improvements.” from the report
Inspectors raised no specific concerns in this report.
- 01How do you now make sure best-interest decisions are recorded and reviewed, including decisions about covert medicines and resuscitation?
- 02How do you check that staffing levels remain sufficient when people's care needs change?
- 03How are medicines audits followed up if an error or missed dose is found?
- 04What activities are available for someone who prefers individual time or does not want to join group activities?
- 05How will you involve our family member and us in care planning and regular reviews?
This was an unannounced inspection of the overall service, including all five CQC questions, the premises and the care provided. This explanation was written from the published report of 11 January 2018 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Abbcross Nursing Home
5 rated inspections over 9 years: the service has improved, from Requires improvement to Good.
- January 2024Goodcurrent ratingstayed GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2018Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2016Requires improvementstayed Requires improvementSafe: GoodEffective: Requires improvementCaring: Requires improvementResponsive: GoodWell-led: Good
- September 2015Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- April 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- December 2013
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 10 January 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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