CQC report explained · a nursing home
What the CQC found at Abbots Leigh Manor Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Inspectors found suitable risk assessments, enough staff, safe medicine storage and administration, and appropriate action after accidents.
- Effective?
- Good
- This key question was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Caring?
- Good
- This key question was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Responsive?
- Good
- This key question was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Well-led?
- Good
- Inspectors found a positive, person-centred culture, regular audits and good oversight from the provider. People, relatives and staff gave positive feedback about management and communication.
What inspectors found, May 2023
Abbots Leigh Manor Nursing Home: Rated Good; inspectors found safe, kind care and good management, with a few recording and medicines practices to improve.
Inspectors made an unannounced visit on 24 April 2023. Two inspectors spoke with people, relatives and staff. They checked care records, staff records, audits and other information about how the home was run.
The home was rated Good overall. Safe and Well-led were also rated Good. Inspectors found enough staff, safe medicine systems, suitable recruitment checks and systems to protect people from abuse and avoidable harm.
People and relatives described kind care and good communication. Inspectors noted that some best-interests decisions needed more detailed records, more fire escape signs would help, and carrying two people's medicines together on a tray could increase the risk of mistakes.
Kind and sufficient care
People and relatives said staff were kind and caring. They also said there were enough staff to meet people's needs.
“People told us staff were kind and caring and there were enough staff to meet their needs.” from the report
Safe care systems
The home used risk assessments, safeguarding procedures and checks to support people's safety. Staff had training on recognising and reporting abuse.
“People were protected from the risk of abuse because there were systems in place to identify and report concerns.” from the report
Safe medicines arrangements
Staff were trained and checked before giving medicines. Medicines were stored securely and the records checked by inspectors were accurate.
“There were safe procedures in place for administration of medicines. Staff were trained and their competencies checked prior to administering medicines.” from the report
Good oversight
The home carried out regular audits and discussed their results with staff. The provider's senior representatives maintained oversight alongside the registered manager.
“There were systems in place to monitor the quality and safety of the service. Regular audits were undertaken to monitor the home and take any actions necessary to improve.” from the report
Medicines carried together
needs fixingStaff were seen taking two people's medicines together on one tray before administering them in their rooms. No error happened, but inspectors said this could create a risk of mistakes.
“We did note one area of practice that potentially posed a risk of errors being made, whereby staff took two people's medicines together on a tray, to administer in their rooms.” from the report
Fire escape signs
minorInspectors told the provider that additional signs would help people find fire escape routes.
“We discussed with the provider how more signage would be beneficial to direct people towards fire escape routes.” from the report
- 01What changes have you made to record best-interests decisions in more detail?
- 02How do you make sure medicines for different people are not carried together on one tray?
- 03What additional fire escape signs have been installed or are planned?
- 04How do your audits identify and follow up risks in medicines, records and fire safety?
- 05How do you use the dependency tool to make sure staffing levels meet people's needs?
This was a focused inspection of Safe and Well-led only; the other key question ratings were carried over from the previous inspection published on 17 August 2018. This explanation was written from the published report of 23 May 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, April 2021
Abbots Leigh Manor Nursing Home was inspected but not rated; infection control was mostly reassuring, but waste handling and ventilation needed improvement.
This was an announced, targeted inspection on 12 March 2021. It looked at infection prevention and control during the coronavirus pandemic, rather than the full range of care provided.
Inspectors were assured about visitor checks, PPE, testing, safe admissions, cleaning, social distancing and outbreak arrangements. The home was clean, and staff supported people to keep in touch with their families.
Inspectors were not assured that all bins had pedal-operated lids or that clinical waste was always put in the correct bin. They also found that some areas needed better ventilation. These points were raised with the provider.
Clean environment
The home was clean and staff regularly cleaned frequently touched surfaces.
“The home was clean and fresh and there was regular high touch area cleaning such as door handles, light switches, banisters, furniture and buttons for the lifts.” from the report
PPE and testing
Staff had access to PPE and were tested regularly. Most people and staff had received their first vaccine dose at the time of the inspection.
“Staff had access to plenty of personal protective equipment (PPE). There was a weekly testing programme for staff.” from the report
Family contact
Staff helped people stay in contact with their families through telephone and video calls, as well as screened visits.
“The staff team were supporting people to keep in contact with their family with telephone and video calls and visits were being undertaken in the conservatory behind a screen.” from the report
Visitor safety
Visitors had their temperature checked and were provided with PPE and hand-cleaning facilities.
“There was plenty of PPE available for visitors on arrival along with hand sanitiser and hand washing facilities.” from the report
Clinical waste and bins
needs fixingInspectors were not assured that all bins had pedal-operated lids or that clinical waste was always put in a suitable clinical waste bin. This was raised with the provider for action.
“We were not assured all bins had a pedal foot action or that clinical waste was being disposed of into a clinical waste bin so that it could be handled in line with contaminated waste.” from the report
Ventilation
needs fixingSome rooms and shared areas needed more regular ventilation. Inspectors suggested opening windows periodically in areas including corridors, dining areas and lounges.
“During the inspection we found some areas of the home could benefit from increased ventilation.” from the report
- 01Have all bins been changed so they have pedal-operated lids?
- 02How is clinical waste now separated and disposed of safely?
- 03What changes have been made to improve ventilation in the staff room, corridors, dining area and lounges?
- 04What infection control checks are currently carried out for visitors, staff and new admissions?
- 05What were the home's ratings for caring, effective, responsive and well-led care at its previous full inspection?
This was a targeted inspection of infection prevention and control during the coronavirus pandemic; the service was inspected but not rated and the other care quality questions were not assessed. This explanation was written from the published report of 16 April 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 Abbots Leigh Manor Nursing Home
3 rated inspections over 7 years: the service has held its Good rating throughout.
- May 2023Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Abbots Leigh Manor Nursing Home →
- April 2021Inspected but not ratedSafe: Inspected but not rated
Read what inspectors found at Abbots Leigh Manor Nursing Home →
- August 2018Goodstayed GoodSafe: GoodWell-led: Good
- April 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2014
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 24 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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