CQC report explained · a nursing home
What the CQC found at Albany Park Nursing Home
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 had clear risk assessments, enough staff and safe medicines systems. However, inspectors found damaged equipment, dirty or poorly maintained areas, trip and fire risks, and concerns about window safety.
- Effective?
- Good
- Staff were trained and supported. People had food choices, received help with eating and drinking, accessed healthcare and were supported in line with the Mental Capacity Act.
- Caring?
- Good
- People said staff were kind and respectful. Inspectors saw warm communication, support for cultural and religious preferences, and encouragement for people to remain independent.
- Responsive?
- Good
- Care plans were detailed and personalised. Activities were planned with people and included group and one-to-one sessions, community visits and religious or cultural events.
- Well-led?
- Requires improvement
- Managers and staff were approachable and people’s feedback was used. However, audits and management systems did not identify important maintenance problems, and the home remained in breach of good governance requirements.
What inspectors found, October 2023
Albany Park Nursing Home was rated Requires Improvement; care was kind and responsive, but premises and management checks were not reliable.
Inspectors carried out an unannounced inspection. They visited on 21 and 22 June 2023, with inspection activity continuing until 13 July 2023. They spoke with people, relatives and staff, observed care, and checked care records, medicine records, staff files and management paperwork.
The home was rated Good for Effective, Caring and Responsive. People said they felt safe and were treated kindly. Inspectors found enough staff, safe medicines practice, good training, person-centred care plans, healthcare support and a wide range of activities.
The home was rated Requires Improvement for Safe and Well-led. Inspectors found dirty or damaged areas, trip and fire risks, and equipment that was not always secure or maintained. Management audits had failed to identify these problems, so the home breached regulations about premises and good governance.
The overall rating remains Requires Improvement, as it was at the previous inspection. Improvements meant the home was no longer in breach around person-centred care, activities and staffing, but it remained in breach around premises and management oversight.
Enough staff
Staffing levels matched people’s assessed needs. Inspectors saw staff available to support people during the morning and at lunchtime, and no agency staff were being used.
“There were enough staff to ensure people's care and support needs were met.” from the report
Kind and respectful care
People said staff treated them well. Inspectors saw friendly communication and staff supporting privacy, choices, faith and independence.
“We observed staff communication with people was warm, friendly and showed caring attitudes.” from the report
Personalised activities
An activities coordinator involved people in planning activities. The programme included quizzes, music, gardening, hairdressing, community visits and one-to-one sessions.
“There was an activities coordinator in place who involved people on a daily basis on planning activities.” from the report
Safe medicines practice
Medicines were given safely and on time by trained staff whose competence was checked. Ordering, stock control and audits were in place.
“People received their medicines safely and on time.” from the report
Good care planning
Care plans recorded people’s physical and emotional needs, likes and dislikes. They were updated when needs changed and reviewed with people and, where appropriate, relatives.
“People had detailed person-centred care plans which reflected their care and support needs.” from the report
Poor condition of parts of the building
seriousInspectors found dirty bathrooms, damaged bed rail bumpers, stained walls, strong smells, a damaged bed, an unsecured wardrobe, exposed wires and other maintenance or safety concerns.
“We found significant concerns around the maintenance of the home and environment.” from the report
Management checks missed risks
seriousAudits recorded that some equipment was safe or clean when inspectors found otherwise. The maintenance book also did not include the problems found during the inspection.
“Auditing processes failed to identify the issues found around maintenance during the inspection.” from the report
Visiting information was unclear
needs fixingThe manager said there were no longer visiting restrictions, but a care plan still said visits were restricted and had to be booked. CQC recommended reviewing visiting arrangements with people and families.
“We recommend the provider reviews all visiting arrangements and involves people and families in the review.” from the report
No registered manager
needs fixingThere was no registered manager in post at the time of the inspection. The well-led rating remained Requires Improvement.
“At the time of our inspection there was not a registered manager in post.” from the report
- 01Which of the maintenance problems found by inspectors have now been fixed, including damaged beds, bed rail bumpers, bathrooms, flooring and window restrictions?
- 02How do you now check that maintenance audits accurately identify risks, and can we see the current action plan?
- 03What are the current visiting arrangements, and can relatives visit without booking a one-hour appointment?
- 04Who is currently responsible for managing the home while there is no registered manager in post?
- 05How are people and relatives involved in checking whether the improvements have worked?
This was an unannounced inspection covering all five key questions, with visits on 21 and 22 June 2023 and further inspection activity ending on 13 July 2023. This explanation was written from the published report of 5 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, July 2021
Albany Park Nursing Home was rated Requires Improvement; inspectors found kind basic care but staffing, activities and management needed urgent improvement.
This was an unannounced focused inspection on 20 May 2021. Inspectors looked at Safe, Responsive and Well-led, including infection control. They spoke with people, relatives, staff and managers, observed care, and checked care, medicine, staffing and management records.
People generally received care that met their basic needs. Relatives were mostly positive about the care from staff. Medicines were given safely, risks were assessed in detail, and staff recruitment checks were in place.
However, staffing levels did not match the home's own assessment of people's needs. Inspectors also found limited activities, poor communication with relatives, unsafe storage of some cleaning products, some staff not wearing masks, areas in disrepair and weak management checks. Care and activity records were not always accurate.
The overall rating fell from Good to Requires Improvement. The home breached regulations on person-centred care, good governance and staffing. CQC said it would ask for an action plan, monitor progress with the provider and local authority, and return to inspect again.
Safe medicines
Inspectors found that medicines were administered as prescribed, with accurate records and safe storage and disposal.
“People received their medicines safely and as prescribed.” from the report
Detailed risk assessments
Risks linked to people's health and care needs were assessed and reviewed. Staff had clear guidance on how to reduce those risks.
“Risks were assessed, monitored and regularly reviewed to reflect peoples changing needs.” from the report
Safeguarding awareness
Staff understood how to recognise and report possible abuse. Safeguarding concerns had generally been acted on and passed to the appropriate authorities.
“Staff had received training and told us how they kept people safe and would report concerns or abuse.” from the report
Positive views of care staff
Relatives generally spoke positively about the staff who cared for their family members.
“Relatives did speak positively about the care staff that supported their family member.” from the report
Communication support
Care plans included people's communication needs, and staff were observed to understand how to communicate with people.
“We observed that staff knew and understood how to communicate with people.” from the report
Too few staff
seriousThe number of staff on duty did not match the home's own assessment of what people needed. One person waited more than 10 minutes for help to use the toilet.
“Systems and processes in place to determine safe staffing levels were not followed.” from the report
Limited activities and choice
seriousInspectors saw no structured activities during the visit. People were not always offered meaningful activities, meal choices or care that reflected their preferences.
“There was a lack of meaning activities that people could participate in to help stimulate and fulfil their social needs.” from the report
Weak management oversight
seriousAudits failed to identify staffing, infection control, activities and repair problems. Some records did not accurately show what was happening in the home.
“Whilst we found there was no evidence that people had been directly harmed by the issues as identified above, systems were either not in place or robust enough to demonstrate that there was adequate oversight of the home.” from the report
Infection and chemical safety
needs fixingSome staff were not wearing face masks. Hand gel and cleaning liquids were left within easy reach of people, including people living with dementia.
“Bottles of cleaning liquids were also left accessible in the communal lounge.” from the report
Poor family communication
needs fixingRelatives said they were not kept updated about people's health and welfare. Visiting arrangements were not clearly explained when restrictions changed.
“Communication and information about visiting processes had not been forthcoming and relatives were left not able to visit when it was safe to do so.” from the report
Training records
needs fixingInspectors could not be sure that all staff had received the training needed for their roles. Some safeguarding and manual handling refresher training was several years out of date.
“We could not be assured that these staff had received the required training to support them in their role.” from the report
- 01How many care staff and nurses are now planned for each day and night shift, and how is this matched to residents' assessed needs?
- 02What regular activities are now available, including for people living with dementia, and how are residents' interests and preferences recorded?
- 03How are families kept updated about residents' health and welfare, and how are visiting arrangements explained?
- 04What checks now make sure cleaning products and hand gel are securely stored and staff follow mask requirements?
- 05How do you check that staffing, training, care records and activities records are accurate and that problems are corrected promptly?
This was a focused inspection of Safe, Responsive and Well-led only; Effective and Caring were not inspected and their previous ratings carried over into the overall rating. This explanation was written from the published report of 29 July 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 Albany Park Nursing Home
8 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- October 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2021Requires improvementdown from GoodSafe: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- April 2019Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2018Requires improvementstayed Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- September 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- October 2016Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvement
- April 2016Goodup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2014
Report published without a new overall rating.
- April 2014
Report published without a new overall rating.
- May 2013
Registered with the Care Quality Commission on 21 May 2013.
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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