CQC report explained · a residential care home
What the CQC found at Abbeygate Retirement Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Requires improvement
- Some environmental risks were not properly assessed or controlled, including legionella testing and an out-of-date fire risk assessment. Medicines records were incomplete and staff were not always following safe procedures.
- Effective?
- Good
- People received effective care, with regular assessments and care plan reviews. Staff were trained and people received support with food, drink and healthcare.
- Caring?
- Good
- Staff were kind, knew people well and treated them with dignity and respect. People were supported to make choices and remain as independent as possible.
- Responsive?
- Good
- Care was personalised and staff understood people's needs and communication. There was a full daily programme of activities and support to maintain relationships.
- Well-led?
- Good
- Managers were visible, approachable and open about problems. Audits and other systems were used to identify improvements, and concerns found during the inspection were addressed promptly.
What inspectors found, October 2019
Rated Good overall, but Safe was Requires Improvement because some safety checks and medicines records were not reliable.
Inspectors visited on 15 August and 10 September 2019. The first visit was unannounced. They spoke with people, relatives, staff and health professionals, reviewed care and medicines records, checked staff files and maintenance records, and observed meals and activities.
The home was rated Good overall. Effective, Caring, Responsive and Well-led were all rated Good. People were described as receiving kind, personalised care from well-trained staff, with good support for health, food, activities and relationships.
Safe was rated Requires Improvement. Inspectors found that some environmental safety checks were not properly recorded or up to date. They also found problems with medicines records and with staff following safe medicines procedures. The manager took immediate action on the medicines concerns, and inspectors made recommendations about environmental risks and medicines handling.
The overall Good rating means the inspectors found a service that generally provided good care, but safety needed improvement. The previous overall rating was also Good, although the Safe rating had fallen from Good to Requires Improvement.
Kind and respectful staff
People received caring support from staff who knew them well. Staff promoted dignity, choice and independence.
“People benefited from the kind and caring support staff provided.” from the report
Good activities
People had access to daily activities, trips and community links. Inspectors found that activities helped people stay socially connected and mentally engaged.
“There was a full programme of activities daily and staff supported people to access the local facilities on both days we visited.” from the report
Good health and nutrition support
People received support from healthcare professionals and with their eating and drinking. Mealtimes were relaxed, and staff provided discreet help where needed.
“The atmosphere at mealtimes was relaxed and unrushed. The food was hot and nicely presented.” from the report
Open management
The manager was visible and listened to people, staff and professionals. The home had systems for learning from incidents and improving care.
“The registered manager and deputy demonstrated an open and transparent attitude to learning lessons when things went wrong.” from the report
Medicines records and procedures
seriousMedicines records were not always complete or accurate. Staff did not always follow the safe procedure of supporting people to take medicines before signing the administration record.
“We found shortfalls in the completion of medicine records.” from the report
Environmental safety checks
seriousInspectors found that some environmental risks were not properly assessed or controlled. Legionella testing needed improvement, and the fire risk assessment had not been updated in line with guidance.
“Risks to people within the environment were not always appropriately assessed or controlled.” from the report
Accessible information
minorNot all information had been provided in an accessible format, although people said they had the information needed to make decisions.
“Although not all information had been provided in an accessible format people confirmed they had the information they needed to make decisions.” from the report
- 01What changes have you made to medicines records and to the way staff support people to take medicines?
- 02How do you now check that medicine stock records and prescribing instructions are complete and accurate?
- 03Has the fire risk assessment been reviewed and updated, and how are legionella checks recorded?
- 04What evidence can you show that the safety improvements identified after the inspection are being maintained?
- 05How will you provide information in an accessible format for people who need it?
This was a planned inspection that looked at all five key questions, including care, staffing, medicines, records, the building, activities and management systems. This explanation was written from the published report of 30 October 2019 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, February 2017
Abbeygate Retirement Home was rated Good; inspectors found kind, safe and personalised care, with some minor record-keeping issues.
Inspectors visited the home without warning on 18 January 2017. They observed care, spoke with people living there, relatives, staff and healthcare professionals, and checked care records, medicines, recruitment, training and quality checks.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safely managed medicines, suitable training, good food and access to healthcare. People were treated with kindness, dignity and respect, and care plans were detailed and regularly reviewed.
The home had improved since the previous inspection in September 2015. Staffing levels had increased and more activities were available. Inspectors still noted minor inconsistencies in medicine records, some overdue staff supervision and team meetings, and that activities could sometimes be cancelled when staff were busy.
Improved staffing
The home had increased care staffing since the previous inspection. People and relatives told inspectors there were enough staff and that they were not rushed.
“There were sufficient staff to meet people's care and support needs.” from the report
Kind and respectful care
Inspectors saw a calm atmosphere and staff supporting people patiently and warmly. People were encouraged to make choices and remain as independent as possible.
“There was a calm, relaxed atmosphere in the home and staff supported people in a kind and friendly way.” from the report
Personalised support
Care plans gave staff detailed information about people's needs and preferences. Staff reviewed these plans regularly and knew people as individuals.
“People's individual care plans were detailed and well-organised and kept under close review by senior staff.” from the report
Food and healthcare
People were offered choices, including alternatives, and staff understood dietary needs. The home worked with doctors, nurses and therapists when people needed specialist support.
“People were provided with home-cooked food of good quality that met their individual needs and preferences.” from the report
Action after the previous inspection
The home had responded to the earlier concerns about staffing and activities. Inspectors found more stimulation was available and people were satisfied with the activities offered.
“The registered manager and her team had worked hard to address the areas for improvement identified at our last inspection in September 2015.” from the report
Medicine records
needs fixingInspectors found minor inconsistencies in the codes used when people declined medicines. The home also recognised that medicine-cabinet keys were accessible to staff who did not administer medicines and ordered a new key safe.
“We noted some minor inconsistencies in the codes staff had used to record when someone had declined a medicine.” from the report
Overdue staff supervision
needs fixingSome one-to-one staff supervision sessions were overdue. The manager had started scheduling them and expected the backlog to be cleared.
“The registered manager told us that some supervision sessions were now overdue.” from the report
Overdue team meetings
minorThe next round of staff meetings had not happened on time. The manager said they would be rescheduled.
“Team meetings were used to promote coordinated teamwork and effective communication, although we noted that the next round of meetings was overdue.” from the report
Activities could be cancelled
minorA wide programme was planned, but one person said activities sometimes did not take place when care staff were too busy. Activities were delivered by care staff rather than a dedicated activities worker.
“One person told us that sometimes events did not take place if care staff were too busy.” from the report
- 01How were the medicine-recording errors and medicine-cabinet key arrangements corrected after the inspection?
- 02Are staff supervision sessions and team meetings now taking place on schedule?
- 03How do you make sure planned activities still happen when care staff are busy?
- 04How will you review my relative's care plan and risk assessments if their needs change?
- 05How will my relative be supported to make choices and remain independent where possible?
This was an unannounced inspection covering all five CQC questions and the overall quality and safety of the home. This explanation was written from the published report of 21 February 2017 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 Abbeygate Retirement Home
3 rated inspections over 4 years: the service has improved, from Requires improvement to Good.
- October 2019Goodcurrent ratingstayed GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2015Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- September 2014
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 24 November 2010.
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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9 live-in carers within about an hour of 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.
8 can care for a couple. 10 years' experience on average.
“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.”
“Magda was always positive and proactive about trying new things to keep dad busy. She also introduced new ideas for keeping dad healthy.”
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.