CQC report explained · a nursing home
What the CQC found at Alban Manor Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, September 2021
Alban Manor Nursing Home was rated Requires Improvement; inspectors found kind, responsive care but weaknesses in safety records and management systems.
This was the home's first inspection. Inspectors visited unannounced on 2 July 2021 and met the provider on 16 July to discuss the findings and review more evidence. They spoke with people, relatives and staff, and checked care, medicine and management records.
People generally said they felt safe and received kind, personalised care. Staff responded to call bells, infection control procedures were followed, and people were supported with food, drink, health appointments, activities and family contact.
The main problems were incomplete or inaccurate risk assessments and care records. Medicine administration records were not always signed, staff training needed development in some specialist areas, and systems for learning from incidents and checking improvements were not effective enough. The home was rated Good for Effective, Caring and Responsive, and Requires Improvement for Safe and Well-led.
Enough staff
People and relatives said there were enough staff. Inspectors saw staff respond quickly to requests, and staffing levels were adjusted when people's needs changed.
“This meant enough staff were on duty at any one time in order to meet people's needs.” from the report
Kind and respectful care
People said staff treated them with kindness and respect. Staff knew people's preferences and involved people and families in care decisions where possible.
“People told us and we saw that staff treated people in a kind, caring and respectful way.” from the report
Food and healthcare
People had meal choices and received support with nutrition and hydration. Staff arranged referrals and access to healthcare professionals when needed.
“People were supported to access a wide range of health care professionals and people received timely care and treatment.” from the report
Activities and family contact
The home offered activities based on people's interests and helped people stay connected with relatives during the pandemic.
“Staff supported people to maintain regular contact with their families throughout the pandemic.” from the report
Infection control
Inspectors were assured that infection control procedures were followed, including the correct use of protective equipment and cleaning arrangements.
“We were assured the service was following safe infection prevention and control (IPC) procedures, including those associated with COVID-19.” from the report
Inaccurate care and risk records
seriousRisk assessments and care plans were not always accurate or updated when people's needs changed. This could make it harder for staff to follow the right care instructions.
“People's risk assessments were not always accurately completed.” from the report
Weak management checks
seriousAudits identified problems but did not reliably lead to lasting improvements. Incident information was not sufficiently analysed to identify patterns and reduce repeat risks.
“Systems and processes in place to assess, monitor and improve the quality and safety of the service had not been effectively operated.” from the report
Medicine records
needs fixingStaff did not always sign the medicine administration record after giving medicines. Inspectors were reassured by stock checks, but the records themselves were incomplete.
“However, when medicines were administered staff did not always complete the medication administration record [MAR].” from the report
Specialist staff training
needs fixingCare staff had not yet received all the specialist training needed in areas including dementia, choking risks and skin integrity.
“However, additional specific training around areas such as dementia, choking risks and skin integrity had not been provided to care staff.” from the report
Privacy
minorSome people said staff left their bedroom doors open, which affected their privacy. The registered manager said this would be reviewed.
“However, others said that their doors were constantly left open which infringed their privacy.” from the report
End-of-life decisions
seriousDo not attempt resuscitation decisions were not consistently reviewed when people's circumstances changed, including after moving from hospital. Final wishes in care plans also needed more detail.
“DNACPR decisions had not been reviewed when people moved into the home from hospital.” from the report
- 01How have you checked that every person's risk assessment and care plan is accurate and updated when their needs change?
- 02How do you now make sure medicine administration records are signed every time medicines are given?
- 03What specialist training have care staff completed since the inspection, especially for dementia, choking risks and skin integrity?
- 04How do you analyse falls and other incidents to identify patterns and prevent them happening again?
- 05How are do not attempt resuscitation decisions and people's final wishes reviewed when their health or circumstances change?
This was the home's first inspection and covered all five key questions, including infection prevention and control measures; inspectors visited on 2 July and reviewed further evidence on 16 July 2021. This explanation was written from the published report of 17 September 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 Alban Manor Nursing Home
Each visit the CQC has published, newest first, back to the day the home was registered.
- September 2021Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2019
Registered with the Care Quality Commission on 8 May 2019.
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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