CQC report explained · a nursing home
What the CQC found at Ablegrange Severn Heights Limited
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- People did not always receive medicines as prescribed. Inspectors also found unclear medicines records, unsafe storage of cleaning equipment and chemicals, and insufficient window restrictors.
- Effective?
- Good
- This question was not assessed during this focused inspection. Its rating was carried over from the previous inspection.
- Caring?
- Good
- This question was not assessed during this focused inspection. Its rating was carried over from the previous inspection.
- Responsive?
- Good
- This question was not assessed during this focused inspection. Its rating was carried over from the previous inspection.
- Well-led?
- Requires improvement
- Quality checks and oversight were not strong enough to identify and correct problems with medicines and environmental safety. The provider remained in breach of the governance regulation.
What inspectors found, September 2023
Ablegrange Severn Heights Limited is rated Requires Improvement; inspectors found unsafe medicines management, environmental risks and weak oversight, despite some improvements and caring staff.
This was an unannounced, focused inspection on 18 July 2023. Inspectors reviewed care records, medicines records, audits and recruitment checks. They spoke with people, relatives and staff, and observed care in communal areas.
The home was rated Requires Improvement overall, with Safe and Well-led also rated Requires Improvement. Medicines were not always given as prescribed, records were sometimes unclear, and some environmental risks had not been dealt with. The home remained in breach of regulations 12 and 17.
There were also positive findings. Inspectors found enough staff, safe recruitment, good infection control and systems for learning from incidents. People and relatives spoke positively about the caring and respectful approach, but the home did not have a registered manager in post at the time.
Enough staff
Inspectors found enough staff to meet people's individual needs. Recruitment checks included references and Disclosure and Barring Service checks.
“We found there were sufficient staff on duty to meet people's individual needs.” from the report
Infection control
Inspectors were assured about infection prevention, the use of protective equipment and the home's ability to manage an outbreak.
“We were assured that the provider was using PPE effectively and safely.” from the report
Learning from incidents
Incidents and accidents were recorded, reviewed for patterns and used to update care plans and risk assessments.
“Incidents and accidents were reviewed for trends and the outcomes informed updates to care plans and risk assessments to reduce the likelihood of reoccurrence.” from the report
Person-centred culture
Inspectors found that the manager and staff promoted caring, respectful and person-centred support. People and relatives were encouraged to share their views.
“The manager and staff were passionate about always providing good quality person-centred care to people.” from the report
Some improvements
Medicine storage, wound monitoring, mattress checks and electronic care records had improved since the previous inspection.
“This inspection found care record entries were made regularly and accurately reflected the care provided to people to meet their needs.” from the report
Medicines were not always safe
seriousSome medicines were not given as prescribed. Records did not always show clear instructions, reasons for missed doses or the exact dose given.
“People did not always receive their medicines as prescribed.” from the report
Environmental risks
seriousLarge opening windows did not initially have enough restrictors. Cleaning equipment, water and chemicals were also left unattended in a corridor during the inspection.
“Cleaning equipment and chemicals were not always used safely.” from the report
- 01What checks now make sure every medicine is given as prescribed, including bowel medicines and medicines with variable doses?
- 02How do you ensure changes, refusals and missed doses are clearly recorded on medicine administration records and referred for review when needed?
- 03Have all window restrictors now been installed, and how do you prevent cleaning equipment, water and chemicals being left unattended?
- 04What audits are now in place to identify medicine and environmental risks before they affect people?
- 05When will the manager complete registration with CQC, and how will progress against the warning notices be reported to families?
This was a focused inspection of Safe and Well-led only; the Effective, Caring and Responsive ratings were carried over from the previous inspection. This explanation was written from the published report of 20 September 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, February 2023
Rated Requires Improvement; inspectors found medicines, risk management and oversight were not consistently safe.
This was an unannounced focused inspection after concerns about the quality and safety of care and access to health advice. Inspectors visited on 22 and 23 November 2022, spoke with people, relatives, staff and a health professional, and reviewed care, medicines and management records.
The home had enough staff and people were protected from abuse. Staff were recruited safely, supported people to eat and drink, and helped them access health professionals. People and relatives generally described staff as kind, approachable and knowledgeable.
However, medicines records were not always accurate. Some risks, care instructions, environmental hazards and checks were not managed consistently. The home was rated Requires Improvement overall, with Safe and Well-led also rated Requires Improvement. Effective remained Good.
Enough staff
Inspectors found there were enough staff to care for people, and people did not have to wait long for support. Recruitment checks had been completed before staff started work.
“There were sufficient staff to care for people. One person told us, "There's always enough staff to help.” from the report
Health support
Staff worked with GPs, nurses and other health professionals when people's needs changed. Care plans covered issues such as poor skin health and bowel health.
“Where staff had concerns for people's health this was escalated to other health and social care professionals.” from the report
Choice and involvement
People were offered choices and relatives were involved in important care decisions where appropriate. Inspectors found support was generally least restrictive and based on people's wishes.
“Staff took time to ensure people were offered choices about their care.” from the report
Approachable leadership
People, relatives and staff said senior staff were visible and approachable. Staff said they felt supported to provide good care.
“People, relatives and staff told us senior staff and the registered manager were approachable and visible in the home.” from the report
Medicine recording and storage
seriousMedicine administration records had gaps, and some medicines were given without being recorded. The home could not always show that medicines were stored at the correct temperature or disposed of safely.
“People's medicine administration records had not always been accurately completed to confirm what medicines they received.” from the report
Risk and environmental safety
seriousSome electrical areas, exposed wires, window restrictors, hazardous substances and flammable items were not consistently managed safely. Care plans also did not always give staff clear and up-to-date instructions.
“Improvements were required in the way some risks to people were managed, to ensure these were always addressed.” from the report
Weak quality checks
seriousManagement checks had not identified several problems with medicines, risks, mattresses, care records and the environment. This meant improvements were not always made promptly.
“Checks undertaken by the registered manager and provider had not identified the concerns we found in respect of medicines management and the management of people's risks.” from the report
Further staff training
needs fixingSome staff needed more training in specific care needs, including Parkinson's disease, and in the Mental Capacity Act and Deprivation of Liberty Safeguards.
“We recommend the provider ensures all necessary staff are supported to access further training in relation to Parkinson's disease and MCA and DoLS to ensure they deliver effective care.” from the report
- 01What changes have you made to ensure every medicine given is recorded accurately, including as-required medicines?
- 02How do you now check medicine temperatures, opening dates, expiry dates and disposal?
- 03What action have you taken to make window restrictors, exposed wires, electrical areas and hazardous substances safe?
- 04How are care plans checked to ensure staff have consistent, up-to-date guidance about each person's risks and health needs?
- 05What further training have staff completed in Parkinson's disease, the Mental Capacity Act and Deprivation of Liberty Safeguards?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not assessed in this report. This explanation was written from the published report of 2 February 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.
Every inspection of Ablegrange Severn Heights Limited
5 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- September 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Ablegrange Severn Heights Limited →
- February 2023Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
Read what inspectors found at Ablegrange Severn Heights Limited →
- December 2018Goodup from Requires improvementSafe: GoodEffective: GoodWell-led: Good
- March 2018Requires improvementdown from GoodSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- March 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- September 2011
Report published without a new overall rating.
- May 2011
Report published without a new overall rating.
- March 2011
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 26 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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At least 100 live-in carers within about an hour of Worcestershire
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.
Most charge £980 to £1,260 a week. 85 can care for a couple. 9 years' experience on average.
“I have never met a person who is so kind and thinks about others before himself to such an extent as Chris Malagala.”
“She was very caring, kind and patient to all his needs, she built up a wondetful rapport with him, she was dedicated and was there for him through good times as well as through the tough times”
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.