CQC report explained · a residential care home
What the CQC found at Albemarle Rest Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- There were enough staff, people were supported by staff who knew them well, and staff understood how to manage and report risks. Some risk plans and guidance for as-required medicines were not detailed enough.
- Effective?
- Good
- This question was not inspected during this focused visit. Its rating was carried forward from the last comprehensive inspection.
- Caring?
- Good
- This question was not inspected during this focused visit. Its rating was carried forward from the last comprehensive inspection.
- Responsive?
- Good
- This question was not inspected during this focused visit. Its rating was carried forward from the last comprehensive inspection.
- Well-led?
- Requires improvement
- Management oversight had improved, but checks had not identified gaps in risk plans, medicine records and some renewal applications. The provider was no longer in breach, but further improvement was needed.
What inspectors found, October 2022
Albemarle Rest Home was rated Good overall; inspectors found safe, caring support, but leadership and records still required improvement.
This was an unannounced focused inspection. Inspectors visited the home, spoke with people, relatives, staff and a healthcare professional, and checked care, medicines, staffing and management records.
The home was rated Good for Safe. There were enough staff, people were supported by a consistent team, and staff understood how to manage risks and report concerns. Medicines were generally handled safely, although some guidance and records needed improvement.
The home was rated Requires Improvement for Well-led. Management oversight had improved since the previous inspection, but some risk plans, medicine records and renewal applications were not always accurate or timely. The provider was no longer in breach of regulations.
The overall rating rose from Requires Improvement to Good. This was a focused inspection of Safe and Well-led, so the other ratings were carried forward from the previous comprehensive inspection.
Enough staff
Inspectors found there were enough staff to meet people's needs and keep them safe. Relatives also described staffing as consistent.
“There were enough staff to meet people's needs and maintain their safety.” from the report
Staff knew people well
Staff had up-to-date information from handovers and understood people's risks and needs. They recognised when people needed help from healthcare professionals.
“Staff knew people well and recognised when they were ill or needed support from other healthcare professionals to mitigate escalating risks.” from the report
Safe infection control
Inspectors were assured that the home had suitable arrangements to prevent and manage infections, including use of protective equipment.
“We were assured that the provider was responding effectively to risks and signs of infection.” from the report
Open communication
Relatives said staff and managers were approachable and communicated well. Staff also felt supported and listened to.
“Relatives told us they could discuss any aspects of their family member's care with senior staff or the management team whenever they visited the home.” from the report
Working with healthcare professionals
The home shared information well with other professionals and acted on their advice.
“Staff and management worked well with professionals to provide good outcomes for people.” from the report
Risk plans lacked detail
needs fixingSome care plans did not clearly explain how identified risks should be managed. One person's plan did not reflect a change in equipment intended to reduce the risk of skin damage.
“However, systems needed to become further embedded because their checks had not identified some of the concerns we found.” from the report
Medicine records needed improvement
needs fixingGuidance and records for as-required medicines needed more detail. Audits had also missed that opening dates were not always recorded promptly on time-limited medicines.
“Medicines audits has not identified staff were not always recording the date of opening on time limited medicines.” from the report
DoLS renewals were not always timely
needs fixingThe systems for renewing approved legal authorisations before they expired were not always effective.
“Systems to ensure timely applications to renew approved DoLS before they expired were not always effective.” from the report
- 01How do you now check that every person's risk management plan reflects their current equipment and risks?
- 02How do you record and review the reasons for giving as-required medicines?
- 03How do you make sure opening dates are recorded promptly on time-limited medicines?
- 04How do you track and renew approved DoLS authorisations before they expire?
- 05What changes have been made since the inspection to ensure management checks identify record-keeping gaps?
This was a focused inspection of Safe and Well-led, including infection prevention and control; Effective, Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 27 October 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, January 2022
Rated Requires Improvement; inspectors found caring and consistent support, but safety records and management checks were not reliable enough.
This was an unannounced focused inspection on 2 December 2021. Inspectors reviewed Safe and Well-led, spoke with two people, 12 relatives, one professional and five staff, and checked care, medicines, accident and management records.
The home had enough staff and relatives said people were safe and cared for by a consistent team. Staff were trained in safeguarding and medicines, and relatives described the home as friendly, caring and homely.
However, some health risks did not have suitable risk assessments or care plans. Accidents were recorded but not analysed, some covert medicines had been crushed against guidance, and face masks were not always worn correctly. Management checks had not found these problems, so the overall rating fell from Good to Requires Improvement.
Stable staff team
There were enough staff, turnover was low and agency staff were not being used. This gave people consistency from staff who knew them well.
“Staff turnover was low, so people received consistency in care from a staff team who knew them well.” from the report
Positive atmosphere
Relatives described the home as well organised, friendly, caring and homely. Staff also spoke positively about their support and teamwork.
“Relatives gave positive feedback about the way the service was run, the atmosphere and caring culture.” from the report
Safeguarding and recruitment
Staff had safeguarding training and felt confident reporting concerns. Recruitment included references and Disclosure and Barring Service checks.
“Staff were trained in safeguarding and were confident identifying and reporting potential safeguarding incidents.” from the report
Good links with health professionals
The provider worked with district nurses and the GP surgery. A weekly ward round visit was taking place.
“The provider worked closely with district nurses and their G.P surgery and a ward round visit was carried out every week.” from the report
Incomplete risk records
seriousSome known risks were not recorded in suitable risk assessments or care plans. This included falls, diabetes and a hot radiator near a person’s bed.
“Risk assessments were not always in place. Some risks to people's health and safety had not been included in their care records.” from the report
Weak management oversight
seriousAccidents and incidents were recorded but not analysed for patterns or lessons. Audits also failed to identify missing care records and other risks, leading to a breach.
“Quality assurance systems and audits did not identify risk assessments and care plans that were missing from people's care records.” from the report
Covert medicines
needs fixingSome covert medicines were crushed against the manufacturer’s guidance. The provider stopped this practice immediately and said new systems would be introduced.
“Some medicines were being crushed which was against manufacturer's guidance.” from the report
Face mask use
needs fixingThere were occasions when staff did not wear or fit face masks according to guidance. The provider was signposted to further resources.
“There were occasions when face masks were not fitted correctly which meant they slipped below the nose” from the report
- 01What action has been taken to make sure every person has complete risk assessments and care plans, especially for falls and diabetes?
- 02How are accidents and incidents now analysed for patterns, and what changes have resulted from those reviews?
- 03How do you now check that covert medicines are given in line with the manufacturer’s guidance?
- 04What systems are in place to make sure staff wear face masks correctly and follow current infection control guidance?
- 05What progress has been made on the action plan requested by CQC after the Regulation 17 breach?
This was a focused inspection of Safe and Well-led, including infection prevention and control; the other ratings were not assessed and the previous comprehensive ratings were used in calculating the overall rating. This explanation was written from the published report of 14 January 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.
Every inspection of Albemarle Rest Home
4 rated inspections over 7 years: the service has held its Good rating throughout.
- October 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2022Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- April 2018Goodstayed GoodSafe: GoodWell-led: Good
- February 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- October 2011
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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