CQC report explained · a residential care home
What the CQC found at Abbeydale Residential Care Home - Bury
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Medicines, recruitment, infection control and checks on risks had improved. However, the medicines policy was not readily available, controlled drug audits were not in place, and the building layout sometimes meant staff were not close by when people needed help.
- Effective?
- Good
- Staff training, care assessments and communication with health professionals had improved. Inspectors recommended a more systematic way to recognise and respond to medical conditions that may deteriorate.
- Caring?
- Good
- Inspectors observed kind, caring and respectful interactions. People were involved in decisions about their care and staff understood their individual needs.
- Responsive?
- Good
- Care plans and the complaints process had improved, and people could raise concerns. Care plans still needed to be more personalised, while activities and planning for future end-of-life wishes needed further work.
- Well-led?
- Requires improvement
- The new manager had introduced useful audits and created a more positive culture. The provider had not yet demonstrated consistent leadership and robust oversight over a sustained period, and had not yet sought people's and relatives' views through questionnaires.
What inspectors found, February 2023
Abbeydale Residential Care Home - Bury is rated Good overall; inspectors found improved care, but the well-led rating remained Requires Improvement.
Inspectors visited unannounced on 4 January 2023. They spoke with people, relatives, staff and managers. They reviewed care plans, staff files, medicines records and quality checks. They also checked infection prevention and control.
The home had improved since its previous inspection. Inspectors found safe medicines management, better risk checks, improved staff training, kind care and a complaints process. People were supported to make choices and access health services.
There were still areas to improve. The medicines policy was not available to staff, staff were not always visible to people in bedrooms, and care plans were not fully personal. Activities and systems for recognising deterioration also needed strengthening.
The overall rating rose from Requires Improvement to Good. Safe, Effective, Caring and Responsive were rated Good. Well-led remained Requires Improvement because the provider had not yet shown consistent leadership and oversight over a sustained period.
Improved medicines safety
Medicine records were accurate and inspectors found no gaps in administration. Medicines, including controlled drugs, were stored securely.
“Medicine administration records were detailed and accurate. There were no administration gaps seen.” from the report
Kind and respectful care
People were treated with kindness and respect. Staff showed good knowledge of people's personalities, needs and preferences.
“Interactions between staff and people were kind, caring and respectful.” from the report
Better staff preparation
Training and development had improved. New staff received induction and shadowing, and recruitment checks were completed.
“This meant people were now receiving care and support from staff who were trained, skilled and competent in their roles.” from the report
Improved complaints handling
The home had introduced a complaints process and used concerns for learning. People and relatives felt able to raise concerns.
“There was now a complaints process in place and concerns had been dealt with as per the provider's policy.” from the report
Medicines procedures
needs fixingStaff could not access the medicines policy during the inspection. Regular planned audits of controlled drugs were also not in place.
“The medicines policy was not readily available for staff to access if needed and regular planned audits of controlled drugs were not in place.” from the report
Staff visibility
needs fixingThe building layout meant staff were sometimes not visible or close to people in their bedrooms. Inspectors heard one person calling for help and had to get staff attention.
“Due to the layout of the building people could often have periods of time when staff were not visible to people.” from the report
Personalised care plans
minorCare plans had improved but did not fully record people's life histories and preferences. The electronic system prompted tasks that were not always personalised.
“The electronic care planning system in place prompted staff with specific tasks but these were not always personalised to people's preferences.” from the report
Activities
minorActivities had increased, but inspectors found too much reliance on an activities co-ordinator who worked 16 hours a week. People said activities could improve further.
“Although activities were improving, we found there was an overreliance on the activity co-ordinator to deliver this, and they worked 16 hours a week.” from the report
Provider oversight
needs fixingThe provider had not yet shown that leadership and quality oversight were consistent over time. Inspectors said the provider should increase its presence and carry out its own quality visits.
“there was also further scope for the provider to increase their presence at the home and introduce quality visits” from the report
- 01How can staff be reached quickly when someone in a bedroom needs help, and have the planned walkie-talkies been introduced?
- 02Where can staff now access the medicines policy, and how often are controlled drugs audited?
- 03What system is now used to recognise and respond to medical conditions that may deteriorate?
- 04How are care plans being updated to include each person's life history, preferences and future end-of-life wishes?
- 05How are activities being expanded so they do not rely mainly on the activities co-ordinator?
This was an unannounced inspection covering all five key questions, including infection prevention and control; the report also records that the home was not yet able to demonstrate consistent leadership over a sustained period. This explanation was written from the published report of 2 February 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, July 2022
Rated Requires Improvement, with Safe rated Inadequate; inspectors found serious problems with medicines, risks, infection control and management.
This was an unannounced inspection over 24, 25 and 27 May 2022. Inspectors spoke with people, relatives and staff, reviewed care plans, medicines records, a staff file and quality records, and observed care.
The most serious concerns were about medicines, risk assessments, infection control and safe recruitment. Fire drills had not happened for over 12 months. Some staff had not completed essential training, and systems for consent, complaints and quality checks were not working properly.
The home had enough staff on duty and staff generally knew people well. People and relatives described many staff as kind and friendly. However, all five areas were rated below Good. The overall rating fell from Good at the previous inspection, published in March 2018.
Enough staff
Inspectors found suitable numbers of staff on duty. Call bells were answered promptly and staff responded to people's needs in a timely way.
“There were enough staff to meet people's needs and there was a core staff team who knew people well.” from the report
Kind relationships
Staff generally spoke to people kindly and had positive relationships with them. People and relatives gave positive feedback about many staff.
“Relationships between staff and people were friendly and positive.” from the report
Access to healthcare
People were supported to access a range of health professionals, including GPs, dieticians, psychiatrists, speech and language therapists and community nurses.
“People were supported with their heath needs and had access to a range of health care professionals.” from the report
Food choices
People were offered meal choices and inspectors saw that the chef kept records of dietary needs. People said they liked the food.
“The meals are plentiful, we have 3 meals and 2 snacks.” from the report
Medicines were unsafe
seriousMedicines records contained errors and discrepancies. Some medicines were stored insecurely, and inspectors were not assured that all staff were competent to administer medicines.
“People did not always receive their medicines safely and practice was not carried out in accordance with the homes medication policy.” from the report
Risks and emergencies
seriousSome care plans lacked information about health conditions and risks. Fire drills had not taken place for over a year, and staff could not explain the emergency procedure.
“Fire drills at the service had not been undertaken in over 12 months.” from the report
Infection control
seriousInspectors were not assured that personal protective equipment, testing and visitor checks were being used safely and consistently.
“Robust systems were not in place to reduce the risk and spread of infection.” from the report
Training and consent
seriousSome staff had not completed essential training. Mental capacity and Deprivation of Liberty Safeguards records were disorganised, and two safeguards had expired before being reapplied for.
“Staff lacked knowledge of the MCA, DoLS and consent and had not received any recent training on this topic.” from the report
Complaints and activities
needs fixingThe complaints system was disorganised and one relative's complaint had not been recorded. People were not always supported with meaningful activities.
“The provider did not operate an effective accessible system for identifying, receiving, recording, handling and responding to complaints.” from the report
Weak oversight
seriousAudits failed to find the problems identified by inspectors. The home had not regularly sought feedback from people, relatives or staff.
“There was not an effective quality assurance system in place to identify shortfalls and act on them to ensure people were safe.” from the report
- 01What changes have been made to medicines checks, storage, controlled drug records and staff competency assessments since the inspection?
- 02When was the last fire drill, and how are staff tested on the home's emergency evacuation procedure?
- 03How do you check that staff have completed essential training and received regular supervision?
- 04How are mental capacity decisions and Deprivation of Liberty Safeguards now recorded, reviewed and renewed?
- 05What system is now used to record, investigate and respond to complaints and to provide meaningful activities?
This was an unannounced comprehensive inspection covering all five key questions, including infection prevention and control; the previous ratings from March 2018 were reconsidered. This explanation was written from the published report of 9 July 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.
Every inspection of Abbeydale Residential Care Home - Bury
5 rated inspections over 8 years: the service has held its Good rating throughout.
- February 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Abbeydale Residential Care Home - Bury →
- July 2022Requires improvementdown from GoodSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
Read what inspectors found at Abbeydale Residential Care Home - Bury →
- January 2021Goodstayed GoodSafe: Inspected but not rated
- March 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2015GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- October 2013
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- February 2011
Registered with the Care Quality Commission on 2 February 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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