CQC report explained · a nursing home
What the CQC found at Abbey Rose Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that people were protected from avoidable harm. Staffing, recruitment, risk management, medicines and infection control were all found to be safe.
- Effective?
- Good
- This area was not inspected during this focused visit. The report says no concerns were identified from the information held, so the previous rating was used.
- Caring?
- Good
- This area was not inspected during this focused visit. The previous rating was used.
- Responsive?
- Good
- This area was not inspected during this focused visit. The previous rating was used.
- Well-led?
- Good
- Inspectors found clear management arrangements, quality checks and an open culture. The manager acted on concerns and made improvements when issues were identified.
What inspectors found, December 2020
Abbey Rose Care Home was rated Good; inspectors found safe, person-centred care, with some improvements needed in notifications and answering relatives' calls.
This was an unannounced focused inspection on 1 December 2020. Inspectors looked at Safe and Well-led because concerns had been raised about night care and staff support. They spoke with people, relatives, staff and health professionals, and checked care, medicines, recruitment and management records.
The home was rated Good for Safe and Good for Well-led. Inspectors found enough staff, safe recruitment, suitable risk assessments and safe medicines management. They were also assured about infection control, including protective equipment, testing and outbreak arrangements.
People and relatives generally said the care was individualised and that they were involved in decisions. The manager acted quickly when problems were found, including improving night-time recording and systems for sharing information. There had been a delay in notifying CQC about some authorised deprivation of liberty arrangements, but action was taken to improve this.
Safe staffing and recruitment
Inspectors found enough staff to meet people's needs. Recruitment checks, including references and DBS checks, had been completed.
“Staff had been recruited safely. All pre-employment checks had been carried out including the completion of a Disclosure and Barring Service (DBS) check and references.” from the report
Safe medicines
Medicines were recorded and stored safely. There was also guidance for staff about medicines prescribed when needed.
“Medicines were managed safely and in line with good practice guidance.” from the report
Individual care
People and relatives described care that respected personal choices and individual needs. Relatives said they were involved in care decisions.
“People and relatives spoke positively about the service and gave examples of how person-centred care was provided.” from the report
Action when problems arose
The manager responded quickly to incidents and concerns. Improvements included better night-care recording and stronger systems for sharing information with other services.
“The registered manager took action when incidents occurred to minimise the risk of them happening again.” from the report
Infection control
Inspectors were assured that the home had measures to prevent and manage infection, including safe use of protective equipment and access to testing.
“We were assured that the provider was using PPE effectively and safely.” from the report
Delayed notification to CQC
needs fixingThere was a delay in telling CQC about some authorised deprivation of liberty arrangements. The manager said technical problems contributed and took action to improve the notification system.
“There was a delay in informing us when some people had an authorised deprivation of liberty in place.” from the report
Some calls were not answered
minorSome relatives said their phone calls had occasionally gone unanswered. The provider responded by arranging for missed calls to be returned and buying extra mobile handsets.
“Some relatives told us there had been occasions when their phone calls had not been answered.” from the report
- 01How do you now check and record the care people receive at night?
- 02What system is in place to make sure notifications to CQC are sent on time?
- 03How are missed calls from relatives recorded and returned?
- 04What checks are made to ensure medicines prescribed when needed are given appropriately?
- 05How will relatives be involved in reviewing and updating their family member's care?
This was a focused inspection of Safe and Well-led only; the other key question ratings were carried over from previous comprehensive inspections. This explanation was written from the published report of 25 December 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, April 2020
Abbey Rose Care Home was rated Good overall; inspectors found safe, kind and well-managed care, but staff needed to do more to engage people in activities.
This was the home’s first inspection. It was an unannounced, planned comprehensive inspection on 10 and 11 March 2020. One inspector spoke with people, relatives and staff, observed care, and checked care, medicine and management records.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines systems, suitable training, good access to food and healthcare, and care that respected people’s choices, privacy and dignity.
Care plans reflected people’s needs and preferences. Activities and family contact were supported, and complaints were recorded and acted on. However, inspectors saw people sitting passively for long periods when staff did not check whether they wanted conversation, rest or another activity.
The home had a recently appointed registered manager and systems for audits, feedback and learning from incidents. As this was the first inspection, there was no previous rating to compare.
Safe staffing and medicines
Inspectors found enough staff to support people safely. Medicine administration was checked and staff competency was assessed.
“There were sufficient staff to support people.” from the report
Kind and respectful care
People and relatives described staff positively. Inspectors saw staff protecting privacy and supporting independence.
“We observed staff demonstrating this throughout the inspection visit.” from the report
Personalised support
Care plans included people’s likes, dislikes and support needs. Reviews allowed changes to be discussed and acted on.
“Care plans showed people's preferences, likes and dislikes.” from the report
Good oversight
The manager and provider used audits, questionnaires and incident reviews to monitor quality and identify improvements.
“The provider used questionnaires and a range of other methods to engage with people” from the report
People were not always engaged
needs fixingInspectors saw people sleeping or watching television passively for long periods. Staff did not always check what people wanted to do or whether they wanted company.
“We observed staff come in and out of all three lounges and just ignored what we were seeing.” from the report
Recent food complaints
minorThere had been several complaints about meal quality. A new chef had recently been employed and the report says this appeared to have resolved the problem, but families may want to check that improvement has lasted.
“We found there had been several recent complaints about the quality of meals” from the report
- 01How do staff make sure people are offered conversation, rest or activities when the activity coordinator is not leading an activity?
- 02What changes were made after the recent complaints about food, and how do you check that people remain satisfied with meals?
- 03How is staffing decided using the dependency tool, and what happens if staffing levels are lower than planned?
- 04How often are care plans reviewed with residents and relatives, and how are changes in needs put into practice?
This was an unannounced comprehensive inspection covering all five key questions, and it was the home’s first inspection. This explanation was written from the published report of 2 April 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.
Every inspection of Abbey Rose Care Home
2 rated inspections over a year: the service has held its Good rating throughout.
- December 2020Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2020GoodSafe: GoodWell-led: Good
- March 2019
Registered with the Care Quality Commission on 20 March 2019.
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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
At least 100 live-in carers within about an hour of Birmingham
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 £950 to £1,230 a week. 79 can care for a couple. 9 years' experience on average.
“God doesn't make people like her anymore!”
“I have never met a person who is so kind and thinks about others before himself to such an extent as Chris Malagala.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.