CQC report explained · a residential care home
What the CQC found at Abbey Village
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, January 2023
Rated Good overall; inspectors found effective care and strong leadership, but medicines arrangements and staffing monitoring needed improvement.
This was an unannounced focused inspection on 17 and 23 November 2022. Inspectors spoke with people, relatives, staff and health and social care professionals. They also checked care records, medicines records, staff files and management records.
People generally felt safe and said staff were kind. Care plans and risk assessments usually gave staff useful guidance. Staff were trained, safely recruited and supported people with food, healthcare, consent and infection control.
The main concerns were medicines information and staffing. Guidance for some medicines was missing, including instructions for medicines given when needed. People and relatives gave mixed feedback about staffing, although inspectors found staffing levels were safe. The overall rating improved from Requires Improvement to Good, and the home was no longer in breach of regulations.
People felt safe
People said they felt safe and well looked after. Safeguarding concerns had been reported appropriately and staff knew how to respond.
“People felt safe living at Abbey Village.” from the report
Trained and supported staff
The home had systems for induction, training, supervision and competency checks. Recruitment checks were completed before staff were employed.
“A robust process was in place to induct, train and support new staff in their roles.” from the report
Good health support
People were supported to access medical attention when needed. Health professionals said referrals were appropriate and timely.
“People were supported to meet their health needs and access appropriate medical attention when needed.” from the report
Improved management
Leadership and quality monitoring had improved since the previous inspection. Managers responded to feedback and used audits and meetings to drive improvements.
“The provider and registered manager completed a range of audits to help monitor the quality and safety of the service.” from the report
Medicines information was incomplete
needs fixingStaff did not always have enough information to give medicines safely. This included missing guidance for medicines given when needed, missing body maps for some creams, and gaps in other records and checks.
“Detailed guidance on how to administer medicines prescribed as and when needed, known as "when required or PRN" medicines was not always available to staff.” from the report
Staffing experience varied
needs fixingInspectors found staffing levels were safe, but some people said they waited a long time for help. The home was asked to continue monitoring staffing levels and how staff were deployed.
“We found staffing levels were safe, although recognised the availability of staff sometimes impacted on people's experiences.” from the report
- 01What has been done to make sure staff have complete instructions for medicines given when needed?
- 02How are body maps, controlled-drug balance checks and records of thickeners now being checked?
- 03How do you monitor staffing levels and staff deployment when people's needs change?
- 04What is the current plan for the renovation and redecoration work mentioned in the report?
- 05Which caring and responsive ratings carried over from the previous comprehensive inspection?
This was a focused inspection covering Safe, Effective and Well-led; Caring and Responsive were not inspected and their previous ratings were carried over. This explanation was written from the published report of 28 January 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, September 2020
Rated Requires Improvement, with Well-led Inadequate; inspectors found risks, medicines and oversight were not managed reliably.
This was an unannounced focused inspection on 9 and 16 July 2020. The inspector spoke with people, relatives, staff and healthcare professionals, and checked care records, medicines records, staff files, the environment and management documents.
The home had improved infection control, suitable staffing and staff with the skills to support people. People were supported with food, drink, healthcare and decisions about their care.
However, records were not always accurate or up to date. Fire safety checks and drills were incomplete, risks such as dehydration were not managed well, and medicines records and procedures were unsafe. The provider's checks did not find or fix these problems.
The overall rating remained Requires Improvement. Safe and Effective were Requires Improvement, while Well-led had fallen to Inadequate. This was the third consecutive Requires Improvement rating, and the inspection found that earlier improvements had not been completed.
Improved infection control
Cleaning processes, staff training and protective equipment had improved, and current guidance was being followed.
“The provider had improved infection prevention and control practices. Cleaning schedules for the service had been reintroduced and a clear dirty to clean laundry flow was in place.” from the report
Skilled staff
Staff had the training and experience needed to support people, with induction, regular training and supervision in place.
“Staff had the skills and knowledge to appropriately support people.” from the report
Healthcare support
Staff helped people access healthcare and followed professional advice. Relatives were kept informed when concerns arose.
“People's healthcare needs were met in a timely way. Staff supported people to access healthcare services and followed professional advice.” from the report
Choice and involvement
Staff sought people's consent and involved them in decisions. The service also had systems for monitoring applications under the Deprivation of Liberty Safeguards.
“Staff sought people's consent and included people in making decisions.” from the report
Fire safety
seriousNot all fire risk actions had been completed. Some staff had not taken part in drills, night-time drills had not been completed in the past year, and important checks were not recorded.
“Fire safety records were incomplete. Records did not demonstrate monthly testing of emergency lights or weekly checks of fire doors.” from the report
Medicines records and procedures
seriousStaff did not always record when as-needed medicines were given. Some guidance was missing and handwritten records were not always checked, creating a risk of incorrect administration.
“Staff did not record the time 'as and when required' (PRN) medicines were administered.” from the report
Risk and care records
seriousDehydration risks were not properly assessed and food and fluid records were not always accurate or complete. Some best-interest decisions and equipment records were also missing.
“Food and fluid records were not always completed and did not accurately show how much fluid had been offered and drunk, which meant staff could not effectively manage the risk of dehydration.” from the report
Weak management checks
seriousAudits were not detailed or regular enough to find problems. The provider had not completed or reviewed its own checks and had not followed its previous improvement plan.
“The provider did not have a robust system in place to monitor the quality and safety of the service.” from the report
Delays for some people
minorStaffing levels met people's needs overall, but some people said they sometimes had to wait for staff support.
“Though some people told us at times they had to wait a while for staff to support them.” from the report
- 01How are you recording the time that as-needed medicines are given, and who checks these records?
- 02Have all fire risk assessment actions been completed, including night-time fire drills and checks of emergency lights and fire doors?
- 03How do you assess and monitor each person's risk of dehydration, and how do you check food and fluid records are accurate?
- 04What changes have been made to the provider's audits since this inspection, and how often are they now completed and reviewed?
- 05How are missing best-interest decisions and care records being identified and corrected?
This was a focused inspection of Safe, Effective and Well-led only; the Caring and Responsive ratings were not reassessed and the previous ratings for areas not inspected were used in the overall rating. This explanation was written from the published report of 2 September 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 Village
5 rated inspections over 7 years: the service has held its Good rating throughout.
- January 2023Goodcurrent ratingup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2020Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Inadequate
- October 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- September 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- January 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2013
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 26 January 2011.
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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32 live-in carers within about an hour of North Lincolnshire
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 £1,300 a week. 29 can care for a couple. 11 years' experience on average.
“What truly stands out is how mindful and attentive she is to all of my medical needs, always going above and beyond to ensure I’m comfortable and well cared for.”
“Martin was more than a carer, he managed the home and became my uncle's best friend, enriching his life during his last few years.”
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.