CQC report explained · a residential care home
What the CQC found at Abbey Grove Residential Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors were assured that the home was preventing and managing infection risks. This included the use of PPE, testing, cleaning, social distancing and safe admissions.
- Effective?
- Good
- This area was not rated in this targeted inspection.
- Caring?
- Good
- This area was not rated in this targeted inspection.
- Responsive?
- Good
- This area was not rated in this targeted inspection.
- Well-led?
- Good
- This area was not rated in this targeted inspection.
What inspectors found, March 2021
Abbey Grove Residential Home was inspected but not rated; inspectors found good infection control arrangements during the COVID-19 pandemic.
This was an announced, targeted inspection on 25 February 2021. It looked at how the home was preventing and controlling infections during the coronavirus pandemic.
Inspectors found the premises were clean and well maintained. Staff used personal protective equipment appropriately, cleaning schedules were followed and COVID-19 testing was taking place in line with guidance.
Visitors were restricted under local infection control guidance. Staff helped people keep in touch with relatives and friends through telephone calls, window visits and online video calls. Inspectors were assured about the home's infection control arrangements.
The home was inspected but not rated. This means the inspection did not give an overall quality rating or full ratings for the five areas of care.
Clean premises
The home was clean and well maintained. Staff followed regular cleaning schedules.
“The premises were clean and well-maintained. Staff followed cleaning schedules to ensure all areas of the home were regularly cleaned.” from the report
Protective equipment and testing
Staff wore PPE appropriately and COVID-19 tests were being carried out in line with good practice guidance.
“We saw staff wore PPE as appropriate.” from the report
Infection control systems
Inspectors were assured that the home had arrangements covering visitors, admissions, testing, hygiene and infection outbreaks.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Keeping people connected
When visits were restricted, staff supported people to contact relatives and friends by telephone, window visits and online video calls.
“During this time staff were supporting people to stay in contact with their relatives and friends via telephone calls, window visits and the use of IT technology such as on-line video calls.” from the report
Inspectors raised no specific concerns in this report.
- 01What infection prevention and control measures are in place now?
- 02How are visitors currently able to see residents safely?
- 03How often are residents and staff tested for COVID-19 now?
- 04How will the home support contact with relatives if visits need to be restricted?
- 05When was the home's most recent full inspection covering all five areas of care?
This was a targeted inspection of infection prevention and control during the coronavirus pandemic; it did not rate the overall service or the other four questions. This explanation was written from the published report of 11 March 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.
What inspectors found, December 2019
Rated Good; inspectors found kind, personalised care, but some risk, consent and record-keeping checks needed improvement.
This was an unannounced inspection of the home. One inspector spoke with three residents, three relatives and six staff. They reviewed care plans, medicines records, recruitment files, training records, complaints and management audits. There were 16 residents at the time, and the home could accommodate up to 19 people.
The home was rated Good overall and received Good ratings for Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe recruitment, clean surroundings, safe medicines administration, kind care and personalised support. People and relatives gave positive feedback about the home.
There were some shortfalls. Fire and legionella risk assessments were not up to date, records for thickened drinks were missing, and some mental capacity and best-interest assessments had not been completed. Annual care reviews were not taking place, and quality checks had not identified all these issues. The manager arranged some documents and assessments after the inspection, and the home was given three recommendations for improvement.
The overall rating and all five question ratings remained Good, as they had been at the previous inspection in March 2017. Good means inspectors found the service met the relevant standards overall, but it was not without areas needing attention.
Enough staff
Inspectors found staffing levels sufficient to meet people’s needs. Residents and relatives also said there were enough staff available.
“Staffing levels were sufficient to care for people safely.” from the report
Kind and respectful care
People and relatives spoke positively about the care. Inspectors observed staff being kind, attentive and respectful.
“Staff were kind and caring and we observed a number of caring interactions between staff and people who lived at the home.” from the report
Personalised support
Care plans included people’s preferences, background and the way they wanted support to be given.
“Care and plans were personalised and detailed how people should be supported with each task.” from the report
Activities and relationships
People were offered activities, trips out and opportunities to maintain relationships. Visitors were welcome, and people could go out with family when they wished.
“People were supported to enjoy a variety of activities and a weekly schedule was on display on the notice board.” from the report
Fire and legionella checks
needs fixingSome environmental risk assessments were not up to date. This meant possible risks might not be identified quickly enough.
“Some environmental risks assessments were not up to date regarding fire safety and legionella.” from the report
Thickened-drink records
needs fixingDrinks thickened for people with swallowing difficulties were being given safely, but there were no records showing when they had been used. A recording document was created during the inspection.
“Medicines were administered safely, however there were no records in place when people's drinks were thickened because they had swallowing difficulties.” from the report
Mental capacity records
needs fixingSome decision-specific mental capacity assessments and best-interest discussions were missing when people refused parts of their care. The manager arranged for these to be completed after the inspection.
“Some best interest discussions and decision specific mental capacity assessments had not been completed” from the report
Quality checks
minorThe home’s own checks had not identified all the issues found by inspectors. Provider audits were said to take place but were not documented.
“Some of the homes quality assurance systems could be strengthened however” from the report
Care reviews
needs fixingAnnual care reviews were not being held. Inspectors recommended that the home address this before the next inspection.
“Annual reviews (or an alternative frequency at the homes discretion) of people's care were not being held at the time of the inspection.” from the report
- 01Have the fire safety and legionella risk assessments been completed and reviewed regularly since the inspection?
- 02How are thickened drinks recorded now, and who checks that these records are complete?
- 03How do you complete and review mental capacity assessments and best-interest decisions when someone refuses care?
- 04How often are residents’ care plans formally reviewed, and are relatives involved where appropriate?
- 05What checks do managers and the provider now carry out to make sure risks, body maps and other records are accurate?
This was an unannounced inspection covering all five key questions, with the overall rating and each question rating remaining Good from the previous inspection. This explanation was written from the published report of 6 December 2019 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 Grove Residential Home
4 rated inspections over 5 years: the service has improved, from Requires improvement to Good.
- March 2021Inspected but not ratedcurrent ratingSafe: Inspected but not rated
Read what inspectors found at Abbey Grove Residential Home →
- December 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Abbey Grove Residential Home →
- April 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2015Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- January 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- November 2013
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 30 December 2010.
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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