CQC report explained · a nursing home
What the CQC found at Abbot Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, October 2023
Rated Requires Improvement; inspectors found staffing, infection control, risk records and management checks needed to improve.
Inspectors visited without notice on 29 August and 4 September 2023. They spoke with people, relatives, staff and a healthcare professional. They reviewed care records, medicines records, staff files and management records.
The first visit found poor cleanliness and infection control, including problems with equipment and storage. The home took immediate action, and the follow-up visit found the premises clean, uncluttered and equipment removed.
The home did not always have enough staff to meet people's needs. Some medicines and risk records were not managed fully safely. People generally felt safe, received healthcare when needed and were supported with consent and best-interest decisions.
The overall rating changed from Good to Requires Improvement. Safe, Effective and Well-led were all rated Requires Improvement. The report identified breaches about staffing and good governance.
People generally felt safe
People and relatives told inspectors that the home was safe. Staff had safeguarding training and knew how to report concerns.
“People and their relatives told us the service was safe.” from the report
Prompt action on cleanliness
The home acted immediately after the first visit. The follow-up visit confirmed that the premises were clean and uncluttered and that equipment had been removed.
“Our follow up visit on the 4 September 2023 confirmed action had been taken to prevent the spread of infection” from the report
Medicines usually administered safely
Qualified nursing staff administered medicines on time, records generally matched stock and staff had medicines training. Some expired liquid medicines and gaps in cream records still needed action.
“People received their medication on time by qualified nursing staff and were generally managed safely” from the report
Access to healthcare
People had access to healthcare professionals when needed. The home made appropriate referrals and worked with professionals such as dieticians and speech and language therapists.
“People had access to healthcare services when they needed them.” from the report
Consent and best-interest decisions
Records showed that decisions for people who lacked capacity were made in their best interests, with family or professional involvement where appropriate.
“Care records showed where people lacked capacity to make certain decisions, these had been made in their best interest” from the report
Not enough staff
seriousMost people and relatives said staffing was insufficient and that they sometimes waited for assistance. Inspectors found that staffing arrangements were not effective enough to meet people's needs.
“Effective arrangements were not in place to ensure there were enough staff available to meet people's needs.” from the report
Infection control and cleanliness
needs fixingInspectors found unclean toilets and equipment, food debris, damaged bed bumpers and cluttered shared bathrooms. The home's infection control audit had not found these problems before the inspection.
“Our visit on the 29 August 2023 identified concerns relating to the cleanliness of the service and infection” from the report
Risk information was inconsistent
needs fixingSome risk assessments had not been updated after a person's circumstances changed. Staff did not always follow the guidance in care plans when people became distressed.
“The information was not always consistent across people's care plans.” from the report
Medicines checks missed problems
needs fixingSome cream applications were not recorded as given, and some medicines were past their expiry date after opening. The manager acted after inspectors raised these issues.
“Medicine audits had not identified that some medicine stock had expired.” from the report
Mealtime support varied
needs fixingSupport and staff presence at mealtimes differed across the home. Some people waited for dessert or did not receive enough help with food and drinks.
“We found people's mealtime experiences differed across the home.” from the report
Management checks were not reliable
seriousAudits did not identify several problems with infection control, medicines, staffing and mealtimes. Inspectors found that this placed people at risk of harm or poor-quality care.
“Systems to monitor and improve the quality of the service were not effective.” from the report
- 01What staffing numbers and skill mix are now in place on each floor, and how do you check they meet residents' needs?
- 02How do you now check that medicines are within date, creams are applied as prescribed and all applications are recorded?
- 03How are risk assessments updated after a resident's mobility or health changes, and how do you make sure the information matches across all care plans?
- 04What changes have been made to mealtime staffing and support, especially for people eating in their bedrooms?
- 05What has changed in the home's audit and management systems since CQC found they had missed problems with infection control, medicines, staffing and mealtimes?
This was an unannounced focused inspection prompted by concerns about safe care and treatment, covering Safe, Effective and Well-led; ratings for any key questions not inspected were carried over from the previous inspection. This explanation was written from the published report of 19 October 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, December 2021
Rated Good; inspectors found safe, kind and well-organised care, but some risk assessments were not fully personalised or up to date.
This was an unannounced focused inspection on 10 November 2021. Inspectors spoke with people, relatives and staff, observed care, and checked care, medicines, recruitment and management records. They also checked infection control arrangements.
The home was rated Good overall. Safe, Responsive and Well-led were also rated Good. Inspectors found that medicines, staffing checks, safeguarding, infection control and complaints systems were being managed safely. People and relatives generally described caring and responsive staff.
There were some shortfalls. A small number of risk assessments did not give up-to-date, personalised guidance for staff. The home was already working to improve these records, following advice from the local authority.
Safe medicines management
Inspectors found that staff were trained and checked as competent. Medicines records were in good order and regular audits were completed.
“Medicine records we reviewed were in good order.” from the report
Kind, person-centred care
Staff knew people well and supported their choices, routines and preferences. Inspectors saw warm interactions, encouragement and unhurried care.
“Our observations showed warm and caring interactions with people, lots of prompting, encouragement and conversation.” from the report
Family communication and activities
The home supported contact with families during the pandemic and offered social, leisure and one-to-one activities.
“The staff actively supported people to maintain relationships with their families and friends.” from the report
Open management
Inspectors found clear responsibilities, regular audits and a management team that worked with staff and outside professionals to improve care.
“The service was well run and managed by an experienced manager and management team.” from the report
Risk records needed updating
needs fixingA small number of assessments did not contain current guidance on how staff should support people with risks. The home was asked to make assessments more personalised and up to date.
“We saw a small number of people's assessments which did not contain up to date information about ways in which to support them.” from the report
Call bells were not always within reach
needs fixingSome family members said call bells were not always close enough for their relative to use. Staff acted quickly when this was raised.
“Some family members told us that when they visited their relative, the call bell (if they could use it) was not always within reach.” from the report
Mixed views about staffing
minorRelatives gave different views about staffing levels. No relative thought their family member was unsafe, but some said staff could be stretched.
“I think they are short staffed, but the staff are absolutely marvellous.” from the report
Satisfaction surveys were not recent
minorRelatives could not remember recently completing satisfaction questionnaires. The manager said this was being planned.
“Family members told us they could not remember recently completing satisfaction questionnaires.” from the report
- 01How have you made sure every risk assessment is personalised and kept up to date?
- 02How do you check that call bells are within reach for people who may need them?
- 03What staffing levels are planned for each unit, and how do you respond when staff are stretched?
- 04When will families next be asked to complete a satisfaction questionnaire?
- 05How will you show us the current care plan and risk assessment for our relative?
This was a focused inspection of Safe, Responsive and Well-led due to a management change and the length of time since the previous inspection; Effective and Caring were not separately rated. This explanation was written from the published report of 11 December 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 Abbot Care Home
4 rated inspections over 6 years: the service has held its Requires improvement rating throughout.
- October 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2021GoodSafe: GoodWell-led: Good
- December 2020Inspected but not ratedSafe: Inspected but not rated
- January 2019Goodup from Requires improvementSafe: GoodEffective: GoodResponsive: GoodWell-led: Good
- November 2017Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- July 2016
Registered with the Care Quality Commission on 26 July 2016.
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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