CQC report explained · a residential care home
What the CQC found at Albury Care Homes Limited
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Staff supported people safely with medicines, risks and infection control, and there were enough staff to provide timely support.
- Effective?
- Good
- This question was not inspected in detail during this focused inspection. Its previous rating was used when calculating the overall rating.
- Caring?
- Good
- This question was not inspected in detail during this focused inspection. Its previous rating was used when calculating the overall rating.
- Responsive?
- Good
- This question was not inspected in detail during this focused inspection. Its previous rating was used when calculating the overall rating.
- Well-led?
- Good
- Management structures, audits and quality checks had improved. Leaders acted on identified actions, worked with other services and listened to people, relatives and staff.
What inspectors found, March 2023
Rated Good; Albury Care Homes Limited had improved its medicines systems and management oversight, with no current breaches found.
This was an unannounced focused inspection on 01 March 2023. Inspectors checked whether the home had improved medicines management and quality monitoring after the previous inspection. They spoke with people, relatives, staff and a healthcare professional, observed care and reviewed records.
The home was rated Good for Safe and Well-led. Inspectors found people were protected from abuse and avoidable harm. Staff understood people's risks, medicines and care needs. There were enough staff, recruitment checks were completed, and infection control arrangements were suitable.
Management systems had improved. Leaders carried out audits, followed up actions and used feedback and incidents to improve care. The home had previously been rated Requires Improvement and had breached regulations 12 and 17. At this inspection, the provider was no longer in breach.
Only Safe and Well-led were inspected in detail. The ratings for the other three questions were carried over from the last comprehensive inspection when calculating the overall Good rating.
Safer medicines systems
Managers regularly checked staff competency and medicines records. They also improved medicines storage and guidance for medicines prescribed to be given when needed.
“The management team made a range of improvements in how medicines were managed in the home.” from the report
Enough staff
People and relatives said staff were available promptly. Inspectors observed call bells being answered quickly, and the provider had recruited more staff since the previous inspection.
“We observed calls for assistance were answered by staff promptly on the day of the inspection.” from the report
People felt safe
People and relatives told inspectors they felt safe and had no concerns about how staff treated them. Safeguarding concerns were investigated and acted on.
“People were protected from abuse and neglect.” from the report
Improved management oversight
The home had clearer management roles and regular checks covering care, safety, staffing, infection control and the environment. Actions were recorded in a service improvement plan.
“The management team had clear structures and systems of oversight of the quality and safety of the service.” from the report
Listening to feedback
The provider acted on people's views, including changing the food arrangements after people said they did not like the food previously offered.
“Staff took action to address people's feedback and improve their experience.” from the report
Small medicines recording gaps
minorChecks found some isolated gaps in signatures on topical medicines records. Managers followed these up and reminded staff to record the support given.
“Where some singular gaps in signatures were identified via checks, the management team took action to check this with staff and reminded them to record support.” from the report
- 01How do you now check medicines storage temperatures and medicines given covertly?
- 02How do you make sure topical medicines records are signed every time?
- 03How often do you review call bell response times and staffing levels?
- 04How are people's care plans and individual risks reviewed after accidents or changes in health?
- 05What recent changes have you made in response to feedback from residents and relatives?
This was an unannounced focused inspection of Safe and Well-led, including infection prevention and control; the other ratings were carried over from the last comprehensive inspection. This explanation was written from the published report of 21 March 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, December 2020
Albury Care Homes Limited rated Requires Improvement; inspectors found kind care but unsafe medicines, delayed support and weak management checks.
This was an unannounced, focused inspection on 27 October 2020. Inspectors looked mainly at whether people were safe and whether the home was well managed. They spoke with people, staff, relatives and a healthcare professional, and reviewed care records, medicines information and management records.
The home was not always safe. Risks were not consistently assessed, medicines records and guidance were incomplete, and some people waited too long for personal care or meals. Inspectors also found that agency staff were not always deployed clearly or supported with the right knowledge and checks.
Management checks had not found these problems. Care plans and daily care records were not always accurate or person-centred, and responsibilities were sometimes unclear. The provider had started an improvement plan and recruited external support, but inspectors said more time was needed to make improvements consistent.
The overall rating changed from Good at the previous inspection, published in November 2017, to Requires Improvement. Only Safe and Well-led were inspected during this visit. The other key question ratings carried over from the earlier inspection.
Kind and supportive staff
People and relatives said staff were kind, caring and supportive when available. People said they felt safe and settled in the home.
“People told us they were happy living in the home, and they felt that staff were kind, caring and supportive when they were available.” from the report
Safeguarding awareness
Staff had safeguarding training and understood the types of abuse, warning signs and reporting procedures.
“Staff had received training in safeguarding. Staff were aware of the potential types of abuse, signs of concerns and reporting procedures.” from the report
Recruitment checks
The provider followed the required recruitment checks for staff files, including background checks, references and training records.
“Staff files contained evidence of a Disclosure and Barring (DBS) check, references were obtained, training completed and a record of the person's interview.” from the report
Healthcare links
The home had developed a good relationship with the local GP service, helping people access additional healthcare support when needed.
“The provider had developed a good relationship with the local GP service. This ensured that people had access to additional healthcare support when they needed it.” from the report
Risks were not consistently assessed
seriousSome people did not have clear plans for health needs or behaviours that could place them or others at risk. Inspectors also found unsafe decorating equipment in an area people could access.
“Risks to people were not always robust or assessed consistently.” from the report
Medicines management
seriousTopical cream records were incomplete, guidance for medicines given when needed was unclear, and some night staff did not have up-to-date competency checks.
“People's medicines were not always being managed safely.” from the report
Delays in care
needs fixingPeople said they often waited for help with washing, dressing, lunch and other support. Staff deployment was not always structured, and records did not always show that checks had been completed.
“Staff were not always deployed to support people in a timely manner.” from the report
Weak management checks
seriousAudits had not identified the problems found by inspectors. Management oversight, care plans and records were not consistently accurate or detailed.
“Quality assurance systems were not always robustly managed to ensure the service was being consistently monitored.” from the report
- 01What has changed since the inspection to make risk assessments complete and consistent for every resident?
- 02How are topical creams and medicines given when needed now recorded and checked?
- 03How do you make sure night and agency staff have the right induction, training and competency checks?
- 04How do you organise staff shifts so residents do not wait too long for personal care, meals or safety checks?
- 05What evidence can you show that your improvement plan and quality audits are now finding and fixing problems?
This was a focused inspection of Safe and Well-led, including infection prevention and control; the other key question ratings carried over from the previous comprehensive inspection. This explanation was written from the published report of 4 December 2020 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 Albury Care Homes Limited
6 rated inspections over 7 years: the service has improved, from Requires improvement to Good.
- March 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2020Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- November 2017Goodup from Requires improvementSafe: GoodWell-led: Good
- March 2017Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Inadequate
- August 2016Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Inadequate
- February 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Inadequate
- November 2013
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 2 December 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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