CQC report explained · a nursing home
What the CQC found at Abbey Wood Park Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People told inspectors they felt safe. Risk assessments, accident reviews, medicines systems, infection controls, staffing levels and recruitment checks were found to be suitable.
- Effective?
- Good
- Staff training, supervision and support had improved. People received suitable food and healthcare, and capacity and best-interest decisions were recorded when needed.
- Caring?
- Good
- People and relatives described staff as kind and caring. Inspectors observed respectful support and found that privacy, dignity, independence and personal choices were promoted.
- Responsive?
- Good
- Care plans were personalised and included people's likes, choices and specific health needs. People were supported with communication, activities, family contact, complaints and end of life decisions.
- Well-led?
- Good
- The management team welcomed feedback and used audits and action plans to improve the home. Staff said they could approach managers with concerns and for help to develop in their roles.
What inspectors found, September 2022
Rated Good; inspectors found safe, kind and personalised care, with substantial improvements since the previous inspection.
Inspectors visited without notice on 18 and 23 August 2022. They spoke with people living at the home, relatives, managers and staff. They observed care, checked the building and equipment, and reviewed care records, medicines records, staff files and management checks.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, robust risk assessments, safe medicines systems and good infection control. People described staff as kind and caring, and inspectors saw warm and familiar interactions.
Care plans reflected people's preferences and changing needs. Staff supported people with food, healthcare, communication, activities, family contact and end of life choices. The home had a complaints process, although no formal complaints had recently been made.
The previous rating was Requires Improvement, published on 27 May 2021. Inspectors found that the provider had acted on the earlier action plan and was no longer in breach of regulations. The report also says previous warning notices relating to Regulations 12 and 17 had been met.
Enough staff
Inspectors saw plenty of staff available in communal areas. Staff said there was enough time to support people without rushing.
“We observed there were plenty of staff in the communal areas of the home ready to assist people with their needs.” from the report
Kind and respectful care
People and relatives spoke positively about staff. Inspectors observed warm interactions and found that privacy, dignity and independence were supported.
“People were treated kindly and with compassion and dignity.” from the report
Personalised care
Care plans included detailed preferences, such as sleeping arrangements, music and activities. People or their families were involved in creating the plans.
“Care plans contained relevant information regarding peoples likes and choices.” from the report
Improved leadership
The home used audits, feedback and action plans to make improvements. Inspectors found significant progress since the previous inspection.
“The management team had a positive attitude regarding feedback and improvement.” from the report
Safer medicines systems
Medicines were stored and given safely. Internal checks had identified improvements, and inspectors found the new systems were embedded.
“Medicines were stored and administered safely and in accordance with people's needs.” from the report
Manager registration was pending
minorA manager was in post but was waiting for an interview as part of an application to register with CQC.
“At the time of our inspection there was a manager in post who had applied to be registered with CQC and was waiting for their interview.” from the report
- 01Has the dementia unit been redecorated, and if not, what remains on the action plan?
- 02What is the current position of the manager's application to register with CQC?
- 03How do you check that medicines records remain accurate and that people receive medicines as prescribed?
- 04How are staffing levels adjusted when people's needs change, including for people at risk of falls?
- 05How are families involved in capacity, best-interest and care-planning decisions?
This was an unannounced comprehensive follow-up inspection covering all five rating areas, including the premises, care and infection prevention and control, after the previous March 2021 inspection. This explanation was written from the published report of 29 September 2022 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, May 2021
Overall rated Requires Improvement, with Safe rated Inadequate and a warning notice issued over risks, medicines, infection control and governance.
This was the home’s first inspection. It was unannounced and took place on 19 March 2021 and 25 March 2021. Inspectors spoke with people, relatives and staff, observed care, checked the building and reviewed care, medicines, recruitment and management records.
Inspectors found serious safety problems. Risks such as falls, bed rails, possible strangulation and pressure damage were not always managed properly. Medicines were sometimes unavailable or did not match records. Infection control procedures, safeguarding reporting and COVID-19 precautions were not consistently followed.
There were also problems with consent, mental capacity decisions, care records and management checks. Inspectors saw some kind and patient care, good support with food, activities and privacy, but these positive aspects were not consistent. The provider had started making changes, including appointing infection control support and strengthening management, but inspectors said improvements still needed to be embedded.
Food and dietary support
People said they were happy with the food. Inspectors found people were supported to have their dietary needs met.
“People were sufficiently supported to ensure their dietary needs were met.” from the report
Kind interactions
Inspectors saw staff being patient and kind, and people appeared comfortable with staff interaction.
“During the inspection, we observed staff being patient and kind with people.” from the report
Privacy and independence
Staff respected people's privacy and supported independence where possible.
“Staff knocked before entering bedrooms and asked for permission to enter rooms.” from the report
Activities and contact
People took part in activities such as arts and crafts and singing. The home had also started COVID-19 safe visiting.
“People were supported to take part in activities. We observed activities taking place during our visits.” from the report
Clean environment
The home was clean and maintained, although infection control practices were not consistently followed.
“One relative praised the standard of cleanliness. They said, "I am impressed with the level of cleanliness.” from the report
People were exposed to safety risks
seriousRisk assessments and safety measures were not always updated or followed. Inspectors found ongoing risks involving falls, bed rails, possible strangulation and skin damage.
“Risk was not always suitably monitored and addressed.” from the report
Medicines were not always safe
seriousSome medicines were out of stock, records did not always match the medicines held, and guidance for medicines used during agitation was incomplete.
“The quantity of medicines in the home did not always match what was on the Medicines Administration Record (MAR).” from the report
Safeguarding incidents were not reported
seriousInspectors found several incidents that exposed people to possible harm. These had not been reported to the local authority safeguarding team for review.
“Accidents and incidents had been recorded on behavioural monitoring charts and in people's daily records, but auditing had not taken place” from the report
Consent and legal safeguards
seriousConsent was not consistently sought. Mental capacity assessments, best-interest decisions and applications to lawfully deprive people of their liberty had not been completed properly or promptly.
“Processes for achieving consent were unclear and inconsistent.” from the report
Weak management checks and records
seriousAudits were missing or ineffective, and care, medicines and evacuation records were incomplete or inaccurate. Inspectors found errors in every care record they reviewed.
“Documentation was not always complete, accurate and up to date.” from the report
Infection control was inconsistent
seriousStaff testing was not fully overseen, masks were not always worn correctly and isolation procedures for new admissions were not always followed.
“On both days of inspection, staff were not always wearing PPE (personal protective equipment) in line with good practice.” from the report
- 01What has been done to make sure falls, bed rails, possible strangulation risks and pressure damage are assessed and managed safely?
- 02How do you now check that medicines are in stock, match the MAR records and are given according to the person's care plan?
- 03How are safeguarding incidents reported to the local authority and reviewed so lessons are learned?
- 04How do you record consent, mental capacity assessments and best-interest decisions, including applications under the Deprivation of Liberty Safeguards?
- 05What audits are now completed, and how can we see evidence that care records and infection control practices are accurate and up to date?
This was the first comprehensive inspection of the newly registered home and covered all five CQC questions, including infection prevention and control. This explanation was written from the published report of 27 May 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 Wood Park Care Home
2 rated inspections over a year: the service has improved, from Requires improvement to Good.
- September 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2021Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- February 2021Inspected but not ratedSafe: Inspected but not rated
- October 2020Inspected but not ratedSafe: Inspected but not rated
- August 2020
Registered with the Care Quality Commission on 28 August 2020.
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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