CQC report explained · a nursing home
What the CQC found at Abbeywell Court
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, June 2023
Abbeywell Court rated Requires Improvement; inspectors found risks, medicines records and dignity of care were not always managed well.
This was an unannounced inspection on 16 and 22 May 2023. Inspectors spoke with people, relatives, staff and a visiting professional. They reviewed care, medicines, staff files and management records.
The home was not always safe. Care plans were sometimes out of date or conflicting. Repositioning records had gaps. Some medicines were not monitored or stored safely, including medicines kept in a refrigerator. Staff had not received epilepsy awareness training.
People were not always treated with dignity and respect. Inspectors saw one person left unattended while eating and another person in distress who did not receive a prompt response. The home acted quickly during the inspection and introduced new systems, updated records and arranged training.
The overall rating is Requires Improvement. Safe, caring and well-led were each rated Requires Improvement. Effective and responsive were not inspected in this visit, so their previous ratings were carried forward into the overall rating.
Safe recruitment
The home completed the required checks before employing staff. Inspectors also found there were enough suitably qualified staff on duty.
“Recruitment files showed all pre-employment checks had been made to ensure only staff who were suitable to work with people were employed.” from the report
People felt safe
People and relatives told inspectors they felt safe in the home. Staff understood how to report suspected abuse.
“People told us they felt safe living in the home and with the staff who supported them.” from the report
Respect for preferences
The home recorded and respected people's cultural beliefs, backgrounds and preferences about support from male or female staff.
“People's preferences and cultural beliefs were respected. People and relatives praised the meaningful activities which took place in the home.” from the report
Open involvement
People, relatives and staff said they could share suggestions and concerns. A visiting professional said the home worked in partnership with other services.
“People, relatives and staff felt involved in the home and felt able to offer suggestions and raise concerns openly.” from the report
Risk records
seriousCare plans were not always current or consistent. Repositioning records had gaps, making it difficult to show that people had been supported as advised.
“Risks to people were not always recorded, assessed or mitigated.” from the report
Medicines management
seriousMedicine allergies were not always shown consistently. Pain patches were not always recorded properly, and refrigerator temperatures were not recorded correctly.
“Medicines were not always managed and monitored safely.” from the report
Dignity and response
needs fixingInspectors saw one person left unattended while eating and another person in distress who did not receive help despite staff being nearby. The manager acted immediately.
“People were not always treated with dignity and respect.” from the report
Epilepsy training
needs fixingStaff had not received epilepsy awareness training even though people with epilepsy lived in the home. Training was arranged during the inspection.
“However, epilepsy awareness training had not taken place.” from the report
Weak quality checks
seriousAudits had not identified several problems found by inspectors, including medicine storage and recording issues and gaps in repositioning records.
“Quality assurance processes were not always effective when monitoring the care and support being provided to people.” from the report
- 01How are you checking that care plans now match each person's current risks and needs?
- 02How do you record repositioning, and what happens if a record is missed?
- 03How are medicine allergies, pain patch placement and medicine refrigerator temperatures checked each day?
- 04What epilepsy training has every relevant staff member completed, and how is their understanding checked?
- 05What evidence can you show that the new quality monitoring systems have prevented the problems found at this inspection?
This was a focused inspection of Safe and Well-led, widened to include Caring; Effective and Responsive were not inspected and their previous ratings carried forward. This explanation was written from the published report of 21 June 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
Abbeywell Court was rated Requires Improvement; inspectors found concerns about risk records, medicines and oversight, although staff knew people's needs and action had started.
This was an unannounced focused inspection on 25 and 26 May 2022. Inspectors looked at Safe and Well-led, spoke with people, relatives and staff, and checked care records, medicine records, audits, policies and staff files.
The home was not always safe. Some risk records were conflicting or out of date, and medicines were not always managed effectively. Staff numbers were considered enough, infection control was mostly effective, and staff knew how to report abuse and learn from incidents.
The home was not always well-led. Its checks had not identified or corrected some problems in care records and medicine protocols. The new manager had started changes, including reviewing records and improving audits, but the overall rating fell from Good at the previous inspection to Requires Improvement.
Staff knew people's needs
Inspectors found staff understood people's risks and how to support them, even though the records did not always show this clearly.
“Staff were aware of people's risks and how to support them, however these risks were not clearly recorded in people's care records.” from the report
Enough staff
People, relatives and staff said there were enough staff. The home was also recruiting permanent staff and had reduced its use of agency nurses.
“People, their relatives and staff confirmed people were supported by enough staff.” from the report
Safeguarding and infection control
Staff knew how to recognise and report abuse. Inspectors were assured about most infection prevention arrangements, including PPE, testing and managing outbreaks.
“Staff were trained to recognise and report any harm or abuse.” from the report
A more positive culture
The new manager was working to improve the atmosphere and staff said things were getting better.
“The atmosphere is very pleasant, everyone is lovely and friendly.” from the report
Risk records were not reliable
seriousSome care records gave conflicting or outdated information about people's risks. This could make it harder to make sure support matched current needs.
“The monitoring of people's risks was not always effectively recorded, and some people's records showed contradicting information or required updates.” from the report
Medicine protocols and administration
seriousSome as-required medicine instructions lacked enough detail or were out of date. Inspectors also found one occasion where staff gave a different medicine from the one prescribed, although no harm was found.
“People's medicines were not always managed effectively.” from the report
Checks did not identify problems
needs fixingThe home's monitoring systems had not picked up all the problems in risk assessments, care plans and medicine protocols. The provider was reviewing its audits.
“The provider's systems to monitor and review the service required improvement.” from the report
Sluice room condition
minorSome sinks had stains and chipped paint, which inspectors said could make them difficult to keep clean.
“However, we found the sluice room sinks had stains and chipped paint which could be hard to keep clean.” from the report
- 01What has been done to make sure each person's risk assessment and care plan now match and are up to date?
- 02How are as-required medicine protocols being rewritten to include the specific signs and symptoms for each person?
- 03What checks now make sure medicines given match the current prescription?
- 04How many permanent staff are currently in post, and how often are agency staff used?
- 05What changes have been made to the audits and the planned falls diary since the inspection?
This was a focused inspection of Safe and Well-led only; the other question ratings were carried forward from the previous inspection published on 19 February 2019. This explanation was written from the published report of 1 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 Abbeywell Court
5 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- June 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- July 2022Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- February 2019Goodup from Requires improvementSafe: GoodCaring: GoodWell-led: Good
- January 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- September 2015GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2014
Registered with the Care Quality Commission on 13 November 2014.
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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