CQC report explained · a residential care home
What the CQC found at Abbey Lodge - Coulsdon
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that people's risks were assessed and managed, staff were safely recruited, medicines were administered safely and the environment was maintained well.
- Effective?
- Good
- This area was not inspected during this visit. Its rating was carried over from the previous inspection when the overall rating was Requires Improvement.
- Caring?
- Good
- This area was not inspected during this focused visit. No new rating was given.
- Responsive?
- Good
- This area was not inspected during this focused visit. No new rating was given.
- Well-led?
- Good
- Inspectors found stronger quality checks, clear staff responsibilities, regular meetings and partnership working with health and social care professionals.
What inspectors found, March 2023
Rated Good after improvements; inspectors found people were safe, medicines were well managed and the home was well led.
This was an announced, focused inspection on 31 January 2023. One inspector spoke with one person, the care manager and the registered manager. They reviewed four care records, four staff files, medicines, the environment, fire safety and quality checks.
The home was rated Good for Safe and Well-led. Inspectors found that risks were assessed, staff were safely recruited, medicines were given as prescribed and infection control arrangements were followed. The home was clean, bright and in good repair.
The previous inspection, published in August 2021, rated the service Requires Improvement and found breaches relating to premises, safe care, staff recruitment and governance. Inspectors found these issues had been addressed and the home was no longer in breach.
The overall Good rating also uses ratings from the previous inspection for the three areas not examined this time. This inspection does not provide new ratings for Effective, Caring or Responsive.
Improved safety
Problems found at the previous inspection had been addressed. The home had hot water, radiator covers, replaced damaged tiles and locked cleaning cupboards.
“At this inspection we found sufficient improvements had been made and the provider was no longer in breach of regulation 15.” from the report
Safe medicines practice
Staff were trained and checked as competent to give medicines. Records had no gaps, medicines were stored securely and stock checks were completed.
“We checked people's MAR charts and found no gaps in recording.” from the report
Suitable staffing
The provider checked employment histories, references and criminal records before new staff started. Inspectors also found enough staff were available to keep people safe.
“The provider ensured new staff had full employment histories, satisfactory references and recent criminal records checks before providing care and support to people.” from the report
Better oversight
Quality audits had become broader and more detailed. They led to practical changes, including new carpets and replacement curtains.
“Since the last inspection the registered manager had improved the range and depth of the quality assurance checks carried out at the service.” from the report
Support for independence
People were supported to set and achieve goals, including moving towards greater independence or services requiring less support.
“The service promoted a positive and empowering culture for people with incremental goals set with and achieved by people towards moving on to greater independence.” from the report
Inspectors raised no specific concerns in this report.
- 01How will you assess and manage my relative's particular mental health and behavioural support needs?
- 02How will you support my relative to work towards greater independence or move on to less supported services?
- 03How do you check that medicines are given correctly and that records remain complete?
- 04What responsibilities would the named keyworker have for my relative's activities, appointments and contact with relatives?
- 05How will my relative and our family be able to raise concerns and influence improvements through meetings or surveys?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried over from the previous inspection. This explanation was written from the published report of 11 March 2023 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, August 2021
Abbey Lodge - Coulsdon was rated Requires Improvement; inspectors found unsafe environmental issues, weak recruitment checks and poor management oversight.
This was an unannounced focused inspection on 13 and 14 May 2021. Inspectors spoke with people, relatives, staff and the manager. They reviewed care, medicines, recruitment and management records, and infection control arrangements.
People were generally safe and supported by staff. Inspectors found personalised risk assessments, safe medicines practices, safeguarding knowledge and suitable infection control measures. Staff numbers were sufficient, and incidents were investigated.
However, some parts of the building and equipment needed repair or replacement. There was no hot water in bedrooms, damaged mattresses and furniture, broken tiles, mould and windows that would not close. Cleaning chemicals were unlocked and some food was out of date. Recruitment records were also incomplete, including missing work histories and expired DBS checks.
The overall rating fell from Good at the previous inspection in 2018 to Requires Improvement. Safe and Well-led were rated Requires Improvement. Effective was inspected but not rated. Caring and Responsive were not inspected at this visit, so their previous ratings were carried forward.
Personalised risk support
Risk assessments and support plans reflected people's needs, preferences and views. Staff knew how to respond when people were struggling with their mental health.
“Individual and environmental risk assessments were detailed and personalised according to individual and service needs.” from the report
Medicines managed safely
Inspectors found that people received their prescribed medicines. Records, stock checks and staff competency checks were in place.
“Our checks of medicines stocks, balances and records showed people received the medicines prescribed to them.” from the report
Staff understood safeguarding
Staff had safeguarding training and knew how to recognise and report abuse. Safeguarding incidents were reported to the local authority when required.
“Staff had received training in safeguarding and could identify the types of abuse.” from the report
Infection control arrangements
Inspectors were assured about the home's infection prevention measures, including PPE, testing, cleaning and visits.
“We were assured that the provider was using PPE effectively and safely.” from the report
Environmental safety
seriousThe home had several maintenance and safety problems, including no hot water in bedrooms, damaged mattresses and furniture, mould, broken tiles and windows that would not close. Chemicals were also left unlocked and some food was out of date.
“There was no hot water in all the bedrooms including the upstairs bathroom.” from the report
Recruitment checks
seriousSome staff had not provided a full employment history and did not have up-to-date DBS checks. This meant the provider could not show that all recruitment checks were complete.
“Not all staff had a full work history and evidence of up to date disclosure and barring service (DBS) checks which is required by law.” from the report
Weak management checks
seriousThe home's audits did not identify important environmental problems. Daily management oversight was insufficient, and some management visits were not recorded.
“From the evidence above, we were not assured that an effective governance system was in place to review the quality and safety of service delivery.” from the report
Food choices and access
needs fixingPeople could choose meals and there was a weekly menu, but inspectors saw little fresh food. It was also unclear why people could not use the kitchen without staff present.
“There were a few brown bananas on the countertop and some chopped melon in the fridge but very little in the way of fresh food.” from the report
- 01Have all bedrooms and bathrooms now had the hot water, broken tiles, mould, damaged mattresses, furniture and window problems fixed?
- 02Can you show that every member of staff has a full employment history and an up-to-date DBS check?
- 03What new environmental audit tool is being used, and how do managers check that problems are found and fixed?
- 04Who provides daily management oversight now that the deputy manager had left, and how are management visits recorded?
- 05How will you give relatives more regular updates and involve them in care decisions?
This was a focused inspection of Safe and Well-led, with a targeted review of Effective; Caring and Responsive were not inspected and previous ratings were carried forward. This explanation was written from the published report of 12 August 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 Lodge - Coulsdon
3 rated inspections over 5 years: the service has held its Good rating throughout.
- March 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2021Requires improvementdown from GoodSafe: Requires improvementEffective: Inspected but not ratedWell-led: Requires improvement
- August 2018GoodSafe: GoodWell-led: Good
- October 2017
Registered with the Care Quality Commission on 18 October 2017.
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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At least 100 live-in carers within about an hour of Croydon
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,230 a week. 77 can care for a couple. 11 years' experience on average.
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“Terry has been of invaluable help to our family while working as a part-time live-in carer for our mother for approximately 6 months”
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