CQC report explained · a nursing home
What the CQC found at Abbey Park
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Requires improvement
- Some people's risk plans were missing or did not clearly explain how staff should respond. Inspectors also found problems with a mattress setting, medicines records and the use of a thickening agent.
- Effective?
- Good
- People's needs were assessed before they moved in. Staff received induction, training and support, and people received help with nutrition, hydration and access to healthcare.
- Caring?
- Good
- People said staff were kind and caring. Inspectors saw warm and respectful interactions, with people's privacy, dignity, choices and independence supported.
- Responsive?
- Good
- Care plans generally reflected people's preferences and staff knew people's routines and needs. Activities were provided daily, although access varied between some dementia units.
- Well-led?
- Good
- The home had a clear management structure and systems for monitoring care, incidents and medicines. Some people and relatives were not aware of opportunities to share their views.
What inspectors found, March 2019
Rated Good overall, but inspectors found that some risks and medicines were not managed consistently.
This was an unannounced, comprehensive inspection on 11 February 2019. Inspectors spoke with people, relatives and staff, observed care, and checked care records, medicines, incidents, complaints and quality checks.
The overall rating was Good. People were described as receiving kind, respectful and personalised care. Staff were trained, people received help with food, drink and healthcare, and activities were available.
Safe was rated Requires Improvement. Some risk plans were missing or unclear, one mattress was set incorrectly, and there were errors or gaps in some medicines records. The other four areas were rated Good.
The home had improved from an overall Requires Improvement rating at the previous inspection. Responsive and Well-led had also improved from Requires Improvement, but the report says safety still needed more consistent management.
Kind and respectful care
People and relatives spoke positively about staff. Inspectors saw staff treating people warmly and respectfully.
“Interactions between staff and people were warm and respectful and responsive.” from the report
Staff training and support
Staff received a comprehensive induction, ongoing training and regular one-to-one support. Nurses also updated their clinical skills.
“Staff received a comprehensive induction at the beginning of their employment which included working alongside other staff to help them get to know people and their needs.” from the report
Support with health and nutrition
People received enough food and drink, including help when needed. Staff arranged healthcare support and monitored people's health.
“People received support from healthcare professionals when needed.” from the report
Personalised activities and end of life care
The home offered daily activities, including one-to-one activities for people cared for in bed. End of life plans recorded people's wishes and relatives were supported.
“People had end of life plans which had been developed to show how the person wished to be supported at this stage of their life.” from the report
Improved management
The home had improved its quality monitoring since the previous inspection. Managers used information about issues such as falls and weight loss to identify trends.
“This had improved during this inspection.” from the report
Missing or unclear risk plans
seriousSome records did not explain clearly how staff should manage important risks, including diabetes, seizures, continence and tube feeding. This could lead to inconsistent care.
“However, one person's care records did not show their care was effectively managed.” from the report
Medicines and swallowing safety
seriousOne medicine was missing from a medicines record, medicine counts did not match the records, and a thickening agent was changed in a way that made the person cough and increased the risk of choking.
“However, when a staff member found the person was not swallowing it, they changed the consistency to make it less thick which made the person cough and placed them at risk of choking.” from the report
Equipment checks not frequent enough
seriousOne specialist mattress was on the wrong setting. Mattresses were checked weekly rather than daily, so similar problems might not be found quickly.
“Mattresses were checked on a weekly basis, as opposed to a daily basis which meant there was a risk these types of issues may not be identified swiftly to keep people safe.” from the report
Family involvement and activities varied
needs fixingSome relatives had not been invited to care reviews, and some people did not know about meetings where they could give feedback. Activities also varied between dementia units.
“However, one relative told us they had discussed their family member's care when the person had moved in, but had not been invited to attend any reviews since.” from the report
- 01What changes have been made to ensure every person has a clear and up-to-date risk plan?
- 02How do you now check specialist mattresses and other equipment, and how often are these checks recorded?
- 03How do you prevent medicines being missed from Medicine Administration Records and make sure medicine counts are accurate?
- 04How do you make sure thickening agents are prepared at the prescribed consistency and that staff follow swallowing guidance?
- 05How will relatives be invited to care plan reviews and informed about resident and relative meetings?
This was an unannounced comprehensive inspection covering all five key questions; the overall rating had improved from Requires Improvement at the previous inspection. This explanation was written from the published report of 19 March 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.
What inspectors found, February 2018
Rated Requires Improvement; inspectors found kind care and good support, but staffing and person-centred care needed improvement.
The inspection took place without warning on 27 September 2017 and continued on 28 September. Inspectors spoke with people, relatives and staff, observed care, and checked care plans, medicines, training, recruitment, complaints and quality records.
People generally felt safe and described staff as kind and respectful. Medicines were managed safely, staff received ongoing training, people had access to health professionals, and meals were suitable for different dietary needs.
However, staffing was not always sufficient on some units. Inspectors saw people waiting for help with meals and personal care. Some people did not receive timely, individual support, and dementia activities and monitoring of some health concerns were not always adequate.
The overall rating fell from Good at the previous inspection in June 2015 to Requires Improvement. The home was in breach of regulations about person-centred care and staffing. The provider was required to send the CQC an action plan, which the CQC said it would check.
Kind and respectful staff
People and relatives spoke positively about staff. Inspectors saw warm conversations, laughter and respectful support with personal care.
“Staff were caring and supportive towards people and we saw all staff warmly interact with people.” from the report
Safe medicines management
Trained staff administered medicines, records showed doses were given, and medicines needing extra checks were checked by two nurses and the deputy manager.
“Medicines were stored, administered and managed safely.” from the report
Suitable food and health support
People could choose meals and where to eat. Dietary needs, allergies and swallowing difficulties were considered, and health professionals were involved when needed.
“People with specific dietary needs had their needs met.” from the report
Respect for privacy and choice
Staff sought consent, protected people's privacy during personal care, and supported people's religious, cultural and personal choices.
“People's privacy and dignity was respected and staff knew how to ensure this was maintained.” from the report
Activities and individual interests
The home offered music therapy, activities and personal projects such as scrapbooks linked to people's past interests and important events.
“We saw action had been taken to pursue people's interests when this was possible.” from the report
Staffing and response times
seriousThere were not always enough staff on some units. People waited for call bells, meals and personal care, and some lounges were briefly left without staff presence.
“We found staffing arrangements were not always sufficient to meet people's needs.” from the report
Mealtime support
needs fixingSome people needed help to eat but waited for assistance. Food was left out of reach or on the floor, and some people waited a long time for meals.
“This did not support a positive mealtime experience for them.” from the report
Person-centred care
seriousSome people's care did not respond promptly to their needs and preferences. Inspectors also found limited dementia resources and people left without meaningful activity.
“People did not always experience care and treatment to meet their needs and preferences.” from the report
Following up health concerns
seriousSome health appointments were not arranged promptly. Inspectors also found that a seriously unwell person did not receive appropriate action to relieve their symptoms.
“During our visit we saw a person was seriously unwell and the nurse in charge had not acted appropriately to meet their deteriorating needs to provide relief for their symptoms.” from the report
Quality checks
needs fixingThe home carried out many audits, but these did not consistently identify problems with staffing and individual care before the inspection.
“Quality monitoring processes had not been fully effective in identifying areas for improvement.” from the report
Nursing supervision
needs fixingNurses had not received regular clinical supervision to update their practice. The manager acknowledged this had fallen behind.
“We identified the nursing staff had not received regular clinical supervision to ensure their nursing practice was updated and they worked to best practice.” from the report
- 01What changes have you made to staffing levels on the nursing and dementia units since the inspection?
- 02How quickly are call bells answered now, and how do you check that people are not waiting too long?
- 03How will you make sure every person gets the help they need to eat and drink at mealtimes?
- 04What activities and resources are now available for people living with dementia?
- 05How are nurses receiving regular clinical supervision, and how are health concerns and deterioration followed up?
This was an unannounced inspection on the first day and an announced inspection on the second day, covering all five CQC questions and the overall quality of the home. This explanation was written from the published report of 9 February 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 Abbey Park
3 rated inspections over 4 years: the service has held its Good rating throughout.
- March 2019Goodcurrent ratingup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2018Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- August 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2014
Report published without a new overall rating.
- May 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- August 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 22 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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