CQC report explained · a nursing home
What the CQC found at Abbey Care Complex
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, December 2022
Rated Requires Improvement; inspectors found gaps in risk assessments, infection control and quality checks, although staffing, medicines and safeguarding were generally safe.
This was an unannounced focused inspection on 25 and 26 October 2022. Inspectors reviewed Safe and Well-led, along with nutrition under Effective. They spoke with people, relatives and staff, observed care, and checked care records, medicines records, recruitment files and management records.
The home was not always safe. Some risk assessments lacked important instructions, including for epilepsy and diabetes. Two pressure-relieving mattresses were set incorrectly. Cleaning schedules did not cover communal areas, and staff were sometimes seen wearing masks below their noses.
The home was also not always well-led. Quality checks had failed to identify problems with risk assessments and cleaning. People and relatives said they were not regularly asked for their views. Food was available and people were supported to eat, but views about its quality were mixed.
The overall rating fell from Good at the previous inspection to Requires Improvement. Safe and Well-led were rated Requires Improvement. Effective was inspected but not rated, and the other key questions were not inspected at this visit, so their previous ratings were used in calculating the overall result.
Staffing
Most people, relatives and staff said there were enough staff. Inspectors saw staff respond promptly when people needed help.
“We observed staff appeared unhurried and were able to respond in a prompt manner when people needed support” from the report
Medicines
Medicines records were accurate and up to date, with clear records of medicines given and held. The home fixed the broken fridge locks within a few hours.
“Completed medicines charts we saw were accurate and up to date.” from the report
Safeguarding
Safeguarding policies and training were in place. Records showed that allegations of abuse had been reported as required.
“Records confirmed the policy had been followed where there were allegations of abuse.” from the report
Support at mealtimes
People were offered choices and received appropriate help where they needed support to eat. Nutrition and hydration risks were monitored.
“Where people required support from staff to eat, this was provided in an appropriate way.” from the report
Incomplete risk assessments
seriousSome health risks were not properly assessed or explained to staff. This included epilepsy, diabetes and the safe settings for two air mattresses, creating a risk of harm.
“Effective systems had not been established for safely assessing and mitigating risk to people. This placed people at risk of harm.” from the report
Infection control
seriousThere were no cleaning schedules for communal areas, despite the home's own policy requiring them. Staff were also repeatedly seen wearing masks that did not cover their noses.
“Systems had been not established to ensure the proper cleaning of the premises was carried out.” from the report
Weak quality monitoring
seriousMonthly checks did not identify the problems with risk assessments and cleaning. This meant the management systems were not reliably protecting people's safety.
“Effective systems had not been established for the purposes of quality assurance and monitoring safety within the service.” from the report
Food quality
needs fixingPeople had enough food and drink, but some said the quality was inconsistent or that meals were not always recognisable or enjoyable. The provider was given a recommendation to review menus.
“People and relatives told us they had enough to eat, but had mixed views about the quality of the food.” from the report
- 01What has been done to make sure every person has a detailed risk assessment, especially for epilepsy, diabetes, falls and pressure damage?
- 02How are you checking that pressure-relieving mattresses are set correctly and checked regularly?
- 03What cleaning schedules now cover communal areas, and how do managers check that they are followed?
- 04How will you involve residents and relatives in reviewing the food and gathering their views about the home?
- 05What actions are included in your improvement plan following the breaches of Regulations 12 and 17?
This was an unannounced focused inspection of Safe and Well-led, with nutrition under Effective also reviewed; Effective was not rated and the other key question ratings carried over from the previous inspection. This explanation was written from the published report of 2 December 2022 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, September 2021
Abbey Care Complex was rated Good; inspectors found safe, effective and well-managed care, with one medicine supply problem put right quickly.
This was an unannounced focused inspection on 7 September 2021. Inspectors checked Safe, Effective and Well-led after concerns had been raised about medicines, nutrition, hydration, personal care and the management culture.
The home was rated Good overall and Good for all three areas inspected. Inspectors found enough staff, suitable recruitment checks, risk assessments, infection control measures and systems for reviewing accidents and incidents.
People received support with food, drinks and healthcare. Staff had training and supervision. The home had an open culture and carried out audits to check and improve its work.
One person's as-required medicine had run out, but the provider arranged a new supply quickly. Caring and Responsive were not inspected during this visit, so those parts of the previous comprehensive inspection were used in the overall rating.
Enough staff
Inspectors saw staff responding to people without rushing. Staffing on the day matched the planned rota.
“We observed staff were unhurried in carrying out their duties and able to respond to people in a timely manner.” from the report
Food and drinks
People were offered choices at mealtimes, as well as snacks and drinks. Their food and fluid intake was recorded.
“People were offered a choice at each mealtime and we saw snacks and drinks being offered to people throughout the inspection.” from the report
Healthcare support
The home worked with healthcare professionals, including speech and language therapists, tissue viability nurses, physiotherapists and GPs.
“Records showed people had access to a variety of health care professionals including speech and language therapists, tissue viability nurses, physiotherapists and GPs.” from the report
Quality checks
The provider used audits covering infection control, medicines, care plans and health and safety. An action plan had been created after a review.
“Various audits were carried out. These included audits of infection control practices, medicines, care plans and health and safety.” from the report
Medicine supply
needs fixingOne person's as-required medicine had run out and there was no replacement in stock at the time. The manager arranged a new supply after inspectors raised it.
“We found that a PRN medicine for one person had ran out and there was no more in stock.” from the report
- 01How do you check that as-required medicines are in stock and available before they run out?
- 02How do you monitor people's food and fluid records, and what action do you take if someone is not eating or drinking enough?
- 03How do you provide and monitor personal care, given that this was not inspected during the focused visit?
- 04How do you make sure people's preferences and daily choices are followed, given that Caring and Responsive were not inspected during this visit?
- 05What changes have been made since the concerns about medicines, nutrition, hydration, personal care and management culture were raised?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and their previous ratings were used in calculating the overall rating. This explanation was written from the published report of 29 September 2021 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 Abbey Care Complex
6 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- December 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2021Goodstayed GoodSafe: GoodWell-led: Good
- September 2020Goodstayed GoodSafe: Inspected but not rated
- November 2018Goodup from Requires improvementSafe: GoodEffective: GoodWell-led: Good
- October 2017Requires improvementdown from GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2015GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2014
Report published without a new overall rating.
- December 2013
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 14 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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