CQC report explained · a residential care home
What the CQC found at Abbeyfield House - New Malden
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Inspectors found enough staff, safe medicines systems, appropriate risk assessments, a clean environment and suitable infection control.
- Effective?
- Good
- This key question was not inspected during this focused visit. Its previous rating was carried forward into the overall rating.
- Caring?
- Good
- Staff treated people with kindness, dignity and respect. People were involved in decisions about their care and how they spent their time.
- Responsive?
- Good
- This key question was not inspected during this focused visit. Its previous rating was carried forward into the overall rating.
- Well-led?
- Requires improvement
- Management systems and improvement work had strengthened, but leadership had been unstable. People, relatives and staff wanted better communication about staff changes and rotas.
What inspectors found, July 2023
Rated Good overall; inspectors found safe, kind care, but management and communication still needed improvement.
This was an unannounced focused inspection on 28 June 2023. One inspector and an Expert by Experience spoke with people, relatives and staff. They reviewed care records, the environment, medicines, staffing and management records.
The home was rated Good for Safe and Caring. Inspectors found enough staff, safe medicines systems, clean surroundings and staff who treated people with kindness, dignity and respect. People were involved in decisions about their care and daily lives.
Well-led was rated Requires Improvement. There had been instability in management, which affected staff morale, communication and engagement. The deputy manager had introduced new checks and an improvement plan, but some changes were still being put in place.
The overall rating improved from Requires Improvement to Good. The home was no longer in breach of regulations found at the previous inspection. This inspection did not assess Effective or Responsive, so their previous ratings were carried forward.
People felt safe
People told inspectors they felt safe. Staff knew people's risks and how to support them, and they worked with health professionals when needed.
“They really take care of you. It does feel safe.” from the report
Kind and respectful care
Staff knew people well and treated them with patience, kindness and dignity. They supported independence while staying nearby to help when needed.
“The staff are excellent and always treat my relative with kindness and dignity.” from the report
Safe staffing and medicines
Inspectors found enough staff to meet people's needs and keep them safe. Staff followed systems for administering, recording and storing medicines.
“There were sufficient numbers of staff to keep people safe, meet their needs and spend time engaging with them.” from the report
Improvements were under way
The management team had introduced daily checks, audits and meetings about the improvement plan. Incidents and concerns were investigated and lessons were used to improve practice.
“There was a detailed service improvement plan in place, and the management team were in the process of implementing these improvements.” from the report
Management instability
needs fixingThe registered manager was not overseeing the home day to day at the inspection. The deputy manager was acting up with support from a regional manager after a period of instability.
“It is unsettling and not good for the home to have instability in management.” from the report
Communication about staff changes
needs fixingPeople, relatives and staff reported concerns about staff being moved between units and wanted clearer communication about rotas and changes.
“The biggest improvement would be to have better communication about what is going on with the staff rotas.” from the report
Reliance on agency staff
minorThe home was recruiting a chef and night care workers. Until those roles were filled, agency staff were being used in these positions.
“there was a reliance on agency staff in these positions.” from the report
- 01Is there now a registered manager overseeing the home day to day?
- 02What has been done to improve communication about staff rotas and staff changes?
- 03Have the chef and night care worker vacancies been filled, and is agency staffing still being used?
- 04Which actions in the service improvement plan are complete, and which remain outstanding?
- 05How will the planned key worker system and electronic care planning be introduced?
This was an unannounced focused inspection of Safe, Caring and Well-led only; Effective and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 19 July 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, March 2022
Rated Requires Improvement; inspectors found kind and effective care, but serious safety risks and weak governance led to breaches.
Inspectors visited on 7 January 2022. They spoke with managers, staff and relatives, observed care, and checked care records, medicines, safety systems and other documents. There were 32 people living in the home at the time.
The home was not always safe. A faulty door allowed a person to leave unnoticed, and another person also left on a separate occasion. Risks linked to falls and dementia were not always managed consistently, and lessons were not always learned after incidents.
There were positive findings too. Medicines were managed properly, staffing levels were generally enough, infection control was effective, and people received care that met their needs. Inspectors found staff to be kind and respectful, and activities, food, healthcare and complaints processes were generally good.
The overall rating was Requires Improvement. Effective, Caring and Responsive were rated Good. Safe and Well-led remained Requires Improvement, as they had been at the previous inspection in August 2019. The provider breached regulations about safe care and treatment and good governance.
Medicines
Inspectors found that medicines were obtained, stored, given and disposed of appropriately. Managers also checked medicines practice and records.
“At this this inspection we found medicines were managed well.” from the report
Kind care
People and relatives generally described staff positively. Inspectors found people were treated with kindness, dignity and respect.
“People were supported in a kind, respectful and compassionate manner.” from the report
Care planning
People's needs, preferences and communication requirements were recorded and used to guide their care. Plans were updated when people's needs changed.
“Care plans detailed person's needs, life history, preferences and how they wished their support to be provided.” from the report
Food and healthcare
People received varied food and drink that met their needs. Staff helped people access GPs, hospitals and other healthcare professionals.
“People were supported to eat and drink sufficiently and healthily.” from the report
Infection control
The home had effective infection control arrangements, including staff training, suitable protective equipment and increased cleaning during the COVID-19 pandemic.
“We were assured the service was following safe infection prevention and control (IPC) procedures, including those associated with COVID-19.” from the report
People could leave unnoticed
seriousThe premises were not consistently secure. A faulty door and insufficient monitoring put people, including people living with dementia, at risk of serious harm.
“One person had left the premises unnoticed when they were subject to deprivation of their liberty which put them at risk of serious harm or death.” from the report
Weak learning and checks
seriousIncidents were investigated, but similar risks happened again. The provider's audits had not identified all the risks linked to dementia and safety.
“However, while investigations were carried out, incidents discussed above showed lessons were not always learnt as there had been a repeat of situations which put people at risk of harm.” from the report
Clothing concerns
minorSome relatives said people sometimes wore clothes belonging to someone else. The home said it was working to label clothing more clearly.
“What I can tell you is that I have seen her wearing clothes that are not hers” from the report
- 01What changes have you made to stop people leaving the building unnoticed, and how do you test that doors and security systems remain safe?
- 02How do you identify and manage falls risks, and how do you check that sensor mats and other recommended measures are used every time?
- 03What has changed in your audits so they now identify risks affecting people living with dementia?
- 04How do you make sure lessons from accidents, safeguarding concerns and other incidents are shared and acted on?
- 05How are residents' clothes labelled, sorted and checked so that people do not wear clothes belonging to someone else?
This was a full inspection of the care home, covering all five key questions, including the premises, care provided and infection prevention and control arrangements. This explanation was written from the published report of 10 March 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 Abbeyfield House - New Malden
6 rated inspections over 8 years: the service has improved, from Requires improvement to Good.
- July 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Abbeyfield House - New Malden →
- March 2022Requires improvementstayed Requires improvementSafe: Requires improvementCaring: GoodWell-led: Requires improvement
Read what inspectors found at Abbeyfield House - New Malden →
- August 2019Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2016Requires improvementstayed Requires improvementEffective: Requires improvementWell-led: Requires improvement
- July 2015Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2014
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- March 2011
Registered with the Care Quality Commission on 16 March 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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