CQC report explained · a residential care home
What the CQC found at Abbottswood Lodge Residential Care 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 safe staffing and recruitment, secure medicines practice, fire safety improvements and effective infection control.
- Effective?
- Good
- People's needs were assessed and reviewed. Staff were trained, people were supported with food and drink and healthcare, and decisions were made in line with the Mental Capacity Act.
- Caring?
- Good
- The report does not give a separate Caring rating. Inspectors observed patient support and recorded positive comments from people, relatives and staff about the care.
- Responsive?
- Good
- Care plans were personalised and regularly reviewed. People were supported with communication, activities, visitors and relationships, and there was a complaints process.
- Well-led?
- Good
- Inspectors found an open and inclusive culture, an approachable manager and effective checks on medicines, care plans, health and safety.
What inspectors found, March 2022
Rated Good; inspectors found safe, kind and well-managed care, with some bedrooms still needing upgrading.
The inspection was unannounced and took place on 25, 27 and 28 January 2022. One inspector spoke with people living in the home, relatives and staff. They also checked care plans, medicines, staff recruitment and management records.
The home was rated Good overall. Safe, Effective, Responsive and Well-led were all rated Good. Inspectors found enough safely recruited staff, safe medicines practice, good infection control, suitable training and personalised care.
The rating had improved from Requires Improvement at the previous inspection, published in May 2019. The earlier breaches had been addressed, and the provider was no longer in breach of regulations.
Safe care and staffing
People told inspectors they felt safe. Staff were safely recruited, there were enough staff, and medicines were given as prescribed.
“There were enough staff who were recruited safely. People received their medicines safely.” from the report
Personalised support
Care plans recorded people's needs, preferences and choices. Staff spent time getting to know people and involved them and their relatives in care.
“People's care plans were person centred and contained their individual needs and preferences.” from the report
Food and healthcare
People could choose what they ate and drank. Staff followed professional advice about health and dietary needs.
“We observed staff supported people gently and patiently when they needed assistance to eat.” from the report
Improved leadership
The manager was described as approachable and had improved the service since the previous inspection. Regular audits and checks were in place.
“The registered manager had worked hard to improve the service since the last inspection and had good systems in place to monitor the quality of the service.” from the report
Some bedrooms still need upgrading
minorAlthough shared areas and bathrooms had improved, inspectors said some people's rooms still needed further work.
“People's rooms were being redecorated but still required some upgrading.” from the report
- 01Which bedrooms still need upgrading, and what work is planned and by when?
- 02How will you make sure my relative's care plan reflects their personal preferences and is reviewed regularly?
- 03How are relatives involved in care reviews and kept informed about changes in care?
- 04What activities and support for maintaining family relationships would be available for my relative?
- 05How do you monitor medicines, staffing and care quality between CQC inspections?
The report gives ratings for Safe, Effective, Responsive and Well-led; it does not include a separate Caring rating, and the inspection was prompted by a review of information held about the service. This explanation was written from the published report of 17 March 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, May 2019
Rated Requires Improvement; inspectors found kind care, but serious fire-safety work was still outstanding.
This was an unannounced inspection on 16 April 2019. One inspector reviewed records, watched care and mealtimes, and spoke with people, staff and the manager. The home cared for 13 people.
Inspectors found staff treated people with kindness, respect and dignity. There were enough staff during the inspection, medicines were generally managed safely, people were supported with food and healthcare, and activities helped people stay engaged.
However, fire safety was not managed effectively. The home lacked suitable evacuation equipment and practical fire evacuation training, and some personal emergency evacuation plans were incomplete. Care plans did not always give staff enough detail, and mental capacity assessments and best-interest decisions were not always completed correctly.
The overall rating was Requires Improvement. Safe, Effective, Responsive and Well-led were also Requires Improvement, while Caring was Good. The new provider and manager had started making changes, but inspectors said important systems were too new and fire-safety improvements had not been prioritised according to risk.
Kind and respectful care
People had positive relationships with staff. Inspectors saw staff consistently protect people's dignity, privacy, independence and diversity.
“Our observations of interactions between staff and people using the service showed that they consistently and always respected and promoted people's dignity, privacy, independence and diversity.” from the report
Enough staff and safe recruitment
There were enough staff on duty during the inspection, and staff responded promptly to call bells and people calling out. Recruitment checks were completed before staff started work.
“There were enough staff deployed at the time of our inspection to meet people's needs and keep them safe throughout the day.” from the report
Support with food and health
People could access food and drink throughout the day. Staff supported people patiently at mealtimes and involved healthcare professionals when people needed help with nutrition or health.
“Our observation of mealtime showed staff were patient and supportive whilst encouraging, prompting and assisting people to eat.” from the report
Activities and engagement
The home had introduced a sensory trolley and group activities to promote stimulation and wellbeing. People were seen enjoying the activities.
“Care staff provided interactive group activities throughout the day which people enjoyed.” from the report
Supportive new management
The new manager was visible, open about the work still needed and developing positive relationships with staff and people.
“The new manager had been in post only a few months. Since they had started in post it was evident they were creating an inclusive culture that put people at the heart of the service.” from the report
Fire safety and evacuation
seriousFire-safety recommendations had not been completed. Evacuation plans lacked important personal details, staff had no practical evacuation training, and equipment was missing for people on the first floor.
“The provider did not have evacuation equipment at the top of the stairs for staff to assist people accommodated on the first floor to escape in an emergency.” from the report
Infection control
needs fixingThere was no sluice or equivalent facility for cleaning commodes. Staff said commodes were rinsed in wash basins or the bath, which inspectors said could cause cross infection.
“This was not good practice and put people at risk of cross infection.” from the report
Care plans lacked detail
needs fixingSome care plans did not explain people's individual needs, preferences, triggers or the support required. The electronic system was not linked to a working care plan for every person.
“The sample we looked at required more detailed information to provide staff with the guidance they needed on how to deliver consistent support that was tailored to the individual and responsive to their specific needs.” from the report
Mental capacity decisions
needs fixingDecision-specific mental capacity assessments and best-interest decisions had not been completed for some people whose medicines were given covertly.
“Decision specific mental capacity assessments had not been completed to administer prescribed medicines covertly to some people and the decisions were not being made within the MCA legal framework to ensure they were in their best interest.” from the report
Environment and bathing facilities
needs fixingSome areas were worn, dementia-friendly signs and visual clues were lacking, and bathing equipment and facilities were not always suitable or working.
“The baths on the ground and first floor were too low for people to use safely; one bath was too short and not compatible for hoisting equipment and the other had a hoist chair that was not operational.” from the report
- 01Have all fire-risk assessment recommendations now been completed, and can you show us the current emergency escape plan?
- 02What practical fire evacuation training have staff completed, and what equipment is available for people on the first floor?
- 03How do staff access each person's current care plan, including information about dementia, distress triggers, preferences and personal history?
- 04How do you record mental capacity assessments and best-interest decisions when medicines are given covertly?
- 05What has been done to improve the bathing facilities, dementia-friendly signage and commode cleaning arrangements?
This was a scheduled, unannounced inspection covering all five CQC questions, including the care and premises provided by the home. This explanation was written from the published report of 25 May 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.
Every inspection of Abbottswood Lodge Residential Care Home
2 rated inspections over 3 years: the service has improved, from Requires improvement to Good.
- March 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Abbottswood Lodge Residential Care Home →
- May 2019Requires improvementSafe: Requires improvementEffective: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
Read what inspectors found at Abbottswood Lodge Residential Care Home →
- March 2018
Registered with the Care Quality Commission on 19 March 2018.
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