CQC report explained · a nursing home
What the CQC found at Abbey Ravenscroft Park Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, October 2020
Abbey Ravenscroft Park Nursing Home was rated Good; inspectors found safe care and improved recruitment and infection control, but communication with some healthcare professionals needed improvement.
This was a focused inspection on 16 September 2020. Inspectors checked whether improvements had been made to staff recruitment and infection control. They reviewed records, staffing information and quality checks, spoke with staff and managers, contacted seven relatives and received feedback from three healthcare professionals.
The home was rated Good for Safe and Well-led. Inspectors found enough staff, safer recruitment checks, safe medicines practice and clear risk assessments. The home was clean and had increased infection control measures during the COVID-19 pandemic.
The overall rating stayed Good. This inspection did not look at all five areas. The ratings for Effective, Caring and Responsive were carried forward from the previous comprehensive inspection.
Safer recruitment and staffing
The home had improved its recruitment checks since the previous inspection. Inspectors found enough competent staff to meet people's needs.
“Newly recruited staff had undergone appropriate background checks prior to starting to work with vulnerable people.” from the report
Safe medicines
Medicines were ordered, stored and recorded safely. Staff received training and competency checks before administering medicines.
“Medicines were managed safely, and people received their medication when they should.” from the report
Improved infection control
The home was clean and had increased cleaning, protective equipment and infection control training during the pandemic.
“At this inspection we found that the home was managing infection prevention and control well especially during the COVID-19 pandemic.” from the report
Supportive management
Staff described managers as approachable and supportive. The home used audits, meetings and feedback to monitor and improve care.
“There was a positive culture throughout the service which focused on providing care that was personalised.” from the report
Communication with healthcare professionals
needs fixingSome healthcare professionals said communication with the home could be better and that requested information was not always provided promptly. A later concern involved access for an essential assessment, although the home gave assurances about this.
“some healthcare professionals did comment that communication between them, and the home could be improved” from the report
- 01How do you make sure healthcare professionals receive requested information promptly?
- 02How will healthcare professionals be given safe access when they need to carry out an essential assessment?
- 03What recruitment checks are completed before a new staff member starts work?
- 04How often are infection control training, cleaning and protective equipment checks reviewed?
- 05How will you tell relatives about any changes made after feedback or concerns?
This was a focused inspection of Safe and Well-led, mainly checking recruitment and infection control; the other ratings were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 17 October 2020 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 2018
Rated Good overall, but inspectors found the home Requires Improvement for safety because of recruitment checks, staffing cover and infection control.
This was an unannounced comprehensive inspection on 6 and 17 July 2018. Inspectors spoke with people, relatives, staff and health professionals. They observed care, checked records, medicines, staff files, staffing rosters and parts of the building.
The home had improved since the previous inspection in September 2017. Safeguarding procedures were being followed and medicines were being managed safely. People and relatives generally described the care as kind, effective and responsive.
The overall rating was Good. However, Safe was rated Requires Improvement. Inspectors found incomplete or delayed recruitment checks, staff shortages when people were unexpectedly absent, and minor cleanliness problems. The provider sent action plans after the inspection, but inspectors could not be sure these problems would have been found without their involvement.
Good health support
The home worked with doctors, hospitals and other professionals. Inspectors found that health concerns were identified and acted on.
“The whole service worked in co-operation with other organisations to deliver effective care and support.” from the report
Personalised support
Care plans included people's needs, preferences, communication requirements and interests. Activities were intended to reflect what people enjoyed.
“The service provided personalised care that was responsive to people's needs.” from the report
Improved medicines and safeguarding
The earlier concerns about medicines and safeguarding had been addressed by this inspection.
“At this inspection, we found improvements had been made which addressed the breaches as medicines were now being safely and properly used, and safeguarding procedures were now being followed.” from the report
Recruitment checks
seriousThree of the six newer staff checked had started before an up-to-date DBS disclosure had been seen. Records also showed that references from previous care providers had not always been obtained or reasonably sought.
“Records showed that three of the six newer staff we checked began employment in 2018 before the service had seen an up-to-date DBS disclosure” from the report
Staffing cover
seriousThe planned staffing levels were usually sufficient, but unexpected absences were not always covered. Inspectors found three occasions in a recent two-week period when staffing fell below the home's stated minimum.
“This showed three occasions when unplanned staff absence resulted in less staff than the minimum staffing levels that the registered manager told us” from the report
Cleanliness and infection control
needs fixingInspectors found food stains on some equipment, tablecloths and dining chair legs. People were also not consistently offered the chance to clean their hands before meals.
“During our first visit, we noted people were not consistently offered the opportunity to clean their hands before meals.” from the report
Staff communication
needs fixingSome staff reported poor communication and limited support. Communication records in parts of the home were not being used consistently.
“This feedback indicated weaknesses in the service's working culture.” from the report
- 01How do you now make sure DBS checks and references are completed before new staff start work?
- 02How do you cover unexpected staff absences, and what staffing levels have you achieved recently in practice?
- 03What checks now make sure equipment, dining areas and tables are clean, and that people can clean their hands before meals?
- 04What has changed to improve communication between managers and staff, especially for staff returning from leave?
- 05How do you make sure food and fluid records are completed at the time, rather than from memory?
This was an unannounced comprehensive inspection covering all five key questions, the premises and the care provided. This explanation was written from the published report of 15 August 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. The report was longer than we could read in one go; the later sections may not be reflected.
Every inspection of Abbey Ravenscroft Park Nursing Home
6 rated inspections over 5 years: the service has improved, from Requires improvement to Good.
- October 2020Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Abbey Ravenscroft Park Nursing Home →
- August 2018Goodup from Requires improvementSafe: Requires improvementWell-led: Good
Read what inspectors found at Abbey Ravenscroft Park Nursing Home →
- November 2017Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- October 2017Requires improvementstayed Requires improvementSafe: InadequateEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- May 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- June 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Good
- August 2013
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- July 2011
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 22 November 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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Most charge £980 to £1,300 a week. 83 can care for a couple. 12 years' experience on average.
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