CQC report explained · a residential care home
What the CQC found at Abbeyfield Residential Care Home - The Grove
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, May 2022
Abbeyfield Residential Care Home - The Grove was rated Good; inspectors found improvements in safety and management, but staffing records and learning from incidents still needed work.
This was an unannounced focused inspection on 30 March 2022. Inspectors looked at Safe and Well-led, reviewed records, observed the home and spoke with people, relatives, staff, managers and visiting professionals.
The home was rated Good for Safe and Well-led. Inspectors found improvements in infection control, risk assessments, medicines management, staff recruitment and quality checks. People and relatives said there were enough staff and that managers dealt with issues quickly.
There were still some gaps. Records did not show clearly how staffing numbers had been calculated, cleaning schedules were not always completed, and learning from incidents was not always fully recorded or shared. The home was no longer in breach of regulations found at the previous inspection.
Improved medicines management
Staff had regular competency checks, and records for medicines given when needed were robust. Some people were supported to manage their own medicines safely.
“Medicines were managed safely. Staff were trained and competent in the administration of medicines with 6 monthly reviews of staff competencies taking place.” from the report
Infection control
The home had introduced stronger infection control audits, used appropriate protective equipment and managed visiting safely.
“Staff demonstrated knowledge of how and when PPE should be used to keep people safe.” from the report
Safe recruitment
The home carried out the required employment checks, including DBS checks, before staff were recruited.
“Staff were recruited safely. Employment checks were carried out in line with best practice guidance with staff having DBS checks in place.” from the report
Approachable management
People, relatives and professionals said the management team was approachable and responded promptly to problems.
“People, relatives and visiting professionals all said that the management team were approachable and dealt with issues quickly.” from the report
Staffing calculations were not documented
needs fixingPeople said there were enough staff, and inspectors found no evidence that staffing levels were unsafe. However, records did not show clearly how dependency assessments were turned into the number of staff on duty.
“Dependency assessments were in place, however documentation was not available to show how this translated to the number of staff on duty.” from the report
Learning from incidents was not fully recorded
needs fixingManagers could explain actions taken after accidents and incidents, but the evidence was not comprehensive and was not always shared with staff. A new recording system was introduced during the inspection.
“Lessons had been learnt from incidents however these were not always well recorded or shared.” from the report
Cleaning records were inconsistent
minorNew cleaning schedules had been introduced, but they were not always completed. The manager addressed this with cleaning staff during the inspection.
“Comprehensive cleaning schedules had been introduced since the last inspection, however were not consistently completed.” from the report
- 01How do you now calculate the number of staff needed for the current residents, and can you show us the records?
- 02How do you check that the new system for recording lessons from accidents and incidents is being used?
- 03How are lessons from incidents shared with all relevant staff?
- 04How do you make sure cleaning schedules are completed consistently?
- 05What has changed in medicines management since the previous inspection?
This was an unannounced focused inspection of Safe and Well-led; the other key question ratings were carried forward from the previous inspection. This explanation was written from the published report of 19 May 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, September 2021
Inspected but not rated; the home remained Requires Improvement because infection-control oversight was not strong enough.
This was an unannounced targeted inspection on 21 June and 30 July 2021. Two inspectors checked infection prevention and control. They toured the home, spoke with the registered manager and one care worker, and reviewed visitor, testing and quality records.
Inspectors found that staff were following government COVID-19 guidance. Testing, personal protective equipment, visiting arrangements, isolation and cleaning processes were in place. However, the provider did not have clear checks to show that infection-control processes were being monitored properly.
The inspection was not a full review of the home. The Safe question was inspected but not rated, and the other questions were not reviewed. The previous overall rating of Requires Improvement remained in place. The provider was still in breach of Regulation 12.
Staff followed infection guidance
Inspectors were assured that staff were following government guidance and the home's infection-control processes.
“People were safe from the risk of infection as staff were adhering to government guidelines and following the provider's processes” from the report
Testing and protective equipment
People and staff had access to regular COVID-19 testing, and inspectors were assured that protective equipment was being used safely.
“We were assured that the provider was using PPE effectively and safely.” from the report
Visiting arrangements
Visits took place in designated rooms, with screening and testing arrangements intended to reduce infection risks.
“People could attend visits with their relatives in designated visiting rooms.” from the report
Weak infection-control oversight
seriousThe provider did not have effective monitoring systems or records to show that infection prevention and control was being checked properly. This was a continuing breach of Regulation 12.
“Quality and assurance systems in place did not allow for effective monitoring of infection prevention and control processes in place.” from the report
- 01What action have you taken to improve monitoring of infection prevention and control since this inspection?
- 02Who now checks the infection-control records, and how often are these checks completed?
- 03How do you make sure visitor screening and COVID-19 testing arrangements are recorded and followed?
- 04What progress has been made against the action plan from the previous inspection?
- 05When do you expect the next comprehensive inspection, and what other areas of care will it assess?
This was a targeted inspection of infection prevention and control within the Safe question; it did not assess the other key questions or change the previous Requires Improvement rating. This explanation was written from the published report of 16 September 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 Abbeyfield Residential Care Home - The Grove
5 rated inspections over 7 years: the service has held its Good rating throughout.
- May 2022Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Abbeyfield Residential Care Home - The Grove →
- September 2021Inspected but not ratedSafe: Inspected but not rated
Read what inspectors found at Abbeyfield Residential Care Home - The Grove →
- July 2021Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- February 2020Goodstayed GoodSafe: GoodWell-led: Good
- July 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- March 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 20 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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