CQC report explained · a residential care home
What the CQC found at Abbey House Residential Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found people were protected from abuse and avoidable harm. Staffing, risk assessments, recruitment, infection control and medicines arrangements were generally safe, although medicines recording had some shortfalls.
- Effective?
- Good
- This key question was not inspected during this visit. Its previous rating was used to calculate the overall rating.
- Caring?
- Good
- This key question was not inspected during this visit. Its previous rating was used to calculate the overall rating.
- Responsive?
- Good
- This key question was not inspected during this visit. Its previous rating was used to calculate the overall rating.
- Well-led?
- Good
- The management team was approachable, visible and open to feedback. Governance and record keeping had improved since the previous inspection, although audits had not found every shortfall.
What inspectors found, December 2022
Abbey House Residential Care Home is rated Good; inspectors found safe, kind care, with minor medicines recording shortfalls fixed during the visit.
This was an unannounced focused inspection on 21 November 2022. Inspectors looked only at Safe and Well-led because the visit followed concerns about staffing, moving and handling, and people's safety. They spoke with people, relatives, staff and professionals, observed care, and checked records.
People told inspectors they felt safe and were treated kindly. They found enough staff, suitable risk assessments, safe recruitment, a clean and comfortable home, and good safeguarding arrangements. The home was also managing infection risks, although some PPE bins were not pedal operated and were replaced during the inspection.
The home had improved its management and record keeping since the previous inspection. Inspectors found minor shortfalls in medicines records, including missing second signatures and some irregular recording of medicines given as needed. These issues were dealt with immediately and had not affected people's safety or wellbeing.
The overall rating remained Good. Safe was rated Good and Well-led improved from Requires Improvement to Good. The other three question ratings were carried forward from the previous comprehensive inspection because they were not examined during this visit.
Enough staff
Inspectors found staffing levels were based on people's needs and that people were supported in good time.
“There were enough staff to support people safely.” from the report
Kind, respectful care
People and relatives described staff as kind and caring. Inspectors also observed positive interactions between staff and people.
“People told us that the staff culture was friendly and that all staff engaged with them positively.” from the report
Improved leadership
Management and record keeping had improved since the last inspection. The Well-led rating rose from Requires Improvement to Good.
“At this inspection the rating has improved to Good.” from the report
Clear risk planning
Risk assessments were up to date and gave staff guidance about falls, moving and handling, nutrition, choking and equipment.
“Risk assessments were clear, and up to date.” from the report
Medicines records
needs fixingSome handwritten medicines entries did not have two staff signatures, and there were irregularities in recording one person's medicines given as needed. These issues were addressed immediately and had not affected people's safety.
“The audit however had not picked up the shortfalls we found for example the lack of two staff signatures on handwritten entries into the MAR and some irregularities noted in the recording of one persons' PRN medication.” from the report
Audits missed some gaps
needs fixingThe home's checks did not identify every medicines and PPE shortfall before the inspection. The issues found were corrected during the visit.
“Whilst there were some shortfalls found during the inspection that the audits had not identified, these had not impacted on peoples' good outcomes.” from the report
- 01How do you now check that handwritten medicines records have two staff signatures?
- 02How do you make sure medicines given as needed are recorded correctly and that protocols are in place?
- 03Have all PPE disposal bins been replaced or checked so they can be used safely?
- 04How do your quality audits make sure that medicines and infection control shortfalls are found promptly?
- 05What were the current ratings for Effective, Caring and Responsive at the last comprehensive inspection?
This was a focused inspection of Safe and Well-led only; the other ratings carried over from the previous comprehensive inspection. This explanation was written from the published report of 24 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, May 2019
Rated Good overall; inspectors found safe, kind and responsive care, but leadership and record keeping require improvement.
This was an unannounced, comprehensive inspection carried out over two visits in April 2019. The inspector spoke with people living in the home, managers and staff, and reviewed care, medicines, recruitment, training and management records.
The home was rated Good for safe, effective, caring and responsive care. Inspectors found enough staff, safe medicines practices, clean surroundings, kind staff, suitable activities and support with food, drink and healthcare.
The home was rated Requires Improvement for being well-led. Record keeping was not always accurate or complete. Inspectors found issues with fluid monitoring, an air mattress setting, staff induction records and some maintenance records. The overall rating had improved from Requires Improvement at the previous inspection.
Enough staff
Inspectors found staffing levels were sufficient for people's assessed needs and that staff responded quickly to call bells.
“There were enough staff to meet people's assessed needs and keep them safe.” from the report
Kind care
People were treated with dignity and respect. Staff knew people well and built positive relationships with them.
“People received care that was kind and compassionate.” from the report
Skilled staff
Staff received training, supervision and appraisals. Training included support for people living with dementia and diabetes.
“There were good procedures to ensure staff received the training needed to fulfil their duties.” from the report
Personalised support
The home adapted meals, activities, communication and care to people's individual preferences and needs.
“People's needs were met through good organisation and delivery.” from the report
Incomplete records
needs fixingRecords did not always show clearly whether people had enough to drink, whether staff induction had been completed and whether some care needs had been fully assessed.
“Whilst there had been significant improvements in record keeping we identified a number of areas where record keeping needed to be developed further.” from the report
Fluid monitoring
needs fixingFour people were assessed as at risk of dehydration, but fluid records were not effective enough to confirm accurately that they had received enough to drink. Inspectors said people were seen being offered drinks and did not identify concerns about this in practice.
“However, although people told us they had enough to drink, we found monitoring of fluid intake was not effective.” from the report
Air mattress setting
seriousOne air mattress was set for a weight of 80 kilograms when the person weighed 38 kilograms. Inspectors said this could increase the risk of pressure damage, although no problems with pressure care were identified.
“However, one person's air mattress was set at 80Kgs but the person weighed 38Kgs.” from the report
Outstanding maintenance
needs fixingSome maintenance issues appeared repeatedly in audits, including the bath hoist, external lighting and decoration. There were initially no timescales for completing this work.
“A small number of maintenance tasks were seen to be repeated on each of the audits carried out.” from the report
- 01How do you now check and record people's fluid intake, especially for those at risk of dehydration?
- 02How are air mattresses set to the correct weight, and how often are their settings checked and recorded?
- 03How do you make sure staff induction records are completed before staff work independently?
- 04Which maintenance issues identified in the inspection have now been completed, and what remains outstanding?
- 05How do your current audits show that care records are accurate and up to date?
This was an unannounced, comprehensive inspection covering all five CQC questions; the provider was not asked to complete a Provider Information Return because of technical problems. This explanation was written from the published report of 24 May 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 House Residential Care Home
4 rated inspections over 6 years: the service has improved, from Requires improvement to Good.
- December 2022Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Abbey House Residential Care Home →
- May 2019Goodup from Requires improvementSafe: GoodWell-led: Requires improvement
Read what inspectors found at Abbey House Residential Care Home →
- April 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2017Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- January 2014
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 10 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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