CQC report explained · a residential care home
What the CQC found at Albury House
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, January 2024
Rated Requires Improvement, with an Inadequate well-led rating; inspectors found kind care but serious weaknesses in safety checks, consent, records and management.
This was an unannounced focused inspection. Inspectors visited on 8 November, 17 November and 1 December 2023. They spoke with people, relatives and staff, observed care, and checked care, medicine, staff and management records.
The home had enough staff, people received support with food and healthcare, and staff were seen giving kind, person-centred care. However, checks on lifting equipment were overdue, risks were not always properly assessed, medicines records were not always reliable, and some staff suitability checks were out of date.
The home did not follow the legal rules for mental capacity and deprivation of liberty decisions. Inspectors also found poor oversight, incomplete records, insufficient staff training and failures to display the CQC rating correctly. The overall rating stayed at Requires Improvement, while well-led remained Inadequate. A warning notice was issued and the provider must send an action plan.
Enough staff
Inspectors found there were enough staff on duty to care for people safely.
“There were enough staff on duty to provide care to people.” from the report
Kind, person-centred care
People and relatives spoke positively about the care. Inspectors saw staff who knew people's needs and provided person-centred support.
“People and relatives spoke positively about the care they received. We observed staff giving people person-centred care.” from the report
Food and healthcare
People were supported to eat and drink enough. Staff worked with healthcare professionals and responded when people became unwell.
“People were supported to eat and drink enough to maintain their health.” from the report
Improved healthcare communication
Communication with healthcare partners had improved since the previous inspection, and visiting professionals said staff followed their advice.
“The communication from the home has improved in the past few months.” from the report
Poor management oversight
seriousThe provider had not made enough progress after the previous inspection. Similar problems continued in recruitment, records, consent procedures and regulatory compliance.
“The provider had not taken adequate action since the last inspection to make improvements to the service.” from the report
Risks and equipment checks
seriousSome risks were not fully assessed or acted on. Checks on lifting equipment were overdue by several months, and fire evacuation plans were not always in place.
“Essential checks on lifting equipment were overdue by several months.” from the report
Staff suitability checks
seriousUp-to-date DBS checks were not available for staff, so inspectors could not be sure that staff were safe to work with vulnerable people.
“This meant we could not be sure that staff working at the service were not barred from working with vulnerable people.” from the report
Consent and liberty decisions
seriousThe home did not complete required capacity assessments or record best-interest decisions. Claimed deprivation of liberty applications had not been received or authorised by the local authority.
“Staff had made decisions about people's care for them.” from the report
Incomplete care and medicines records
needs fixingCare records lacked person-centred detail, and medicines records and care plans did not always agree. Inspectors could not be sure that medicine problems were being identified and acted on.
“There were discrepancies between medicines administration records and medicine care plans.” from the report
Staff training and supervision
needs fixingStaff had not received training in the Mental Capacity Act, learning disabilities or autism. Required staff supervisions were also not taking place regularly.
“The provider did not always make sure staff had the skills, knowledge and experience to deliver effective care and support.” from the report
- 01Have all staff now had up-to-date DBS checks, and how do you check that new staff are suitable to work in care?
- 02Have you completed the action plan for risk assessments, fire evacuation arrangements and lifting equipment checks?
- 03How do you record mental capacity assessments, best-interest decisions and any deprivation of liberty applications?
- 04How are medicines audits checked and how do you make sure medicine care plans match administration records?
- 05When did staff last receive training and supervision in the Mental Capacity Act, learning disabilities and autism?
This was a focused inspection of Safe, Effective and Well-led only; the other questions were not inspected and their previous ratings were used to calculate the overall rating. This explanation was written from the published report of 23 January 2024 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, April 2023
Overall Requires Improvement, with Well-led rated Inadequate; inspectors found kind, well-staffed care but significant weaknesses in safety, consent, records and leadership.
This was an unannounced focused inspection. Inspectors visited on 25 October 2022, 29 November 2022 and 19 January 2023. They spoke with people, relatives, managers and staff, and checked care records, medicines, recruitment files, training information and management records.
The home had enough staff and people were supported with food, healthcare, social activities and community access. People and relatives spoke positively about the staff and the cheerful, homely atmosphere. However, inspectors found gaps in fire safety checks, recruitment checks, medicines records, care records and accident monitoring.
The home did not have reliable systems for consent under the Mental Capacity Act and Deprivation of Liberty Safeguards. Its systems for checking quality, reporting incidents, displaying its CQC rating and showing openness when things went wrong were also not effective. The overall rating fell from Good at the previous inspection in 2019 to Requires Improvement, while Well-led was rated Inadequate.
Enough staff
Inspectors found sufficient staff to meet people's care, emotional and social needs. Staff had time to spend with people and supported access to the local community.
“There were sufficient staff deployed to meet people's needs including their emotional and social needs.” from the report
Food and drink
People were supported to eat and drink enough to maintain their health. The home placed emphasis on fresh produce and home baking.
“People were supported to eat and drink enough to maintain their health. There was an emphasis on fresh produce and home baking.” from the report
Positive atmosphere
People, relatives and staff spoke warmly about the home and the care provided. Relatives described it as caring, small and personable.
“There was a cheerful atmosphere at the home. People and relatives spoke positively about the staff and the home.” from the report
Fire safety and risk checks
seriousRecords of building safety checks were not all available. The fire authority had identified several actions needed to protect people in the event of a fire.
“These included the completion of a fire risk assessment, a review of the emergency lighting and updating the existing fire alarm system.” from the report
Consent and DoLS records
seriousThe home could not provide records confirming that a person's Deprivation of Liberty Safeguards application had been submitted or authorised.
“Records were not available to confirm the application had been submitted or authorised and the local authority DoLS team did not have any record of a DoLS application for this person.” from the report
Leadership and governance
seriousThe provider's checks had not identified important problems with safety, records, consent and legal requirements. Inspectors rated the well-led key question Inadequate.
“These issues had not been highlighted by the provider's governance systems.” from the report
Recruitment checks
seriousFull recruitment checks had not been completed for the general manager. The provider also said it planned to renew staff DBS checks.
“Full recruitment checks had not been completed for the general manager.” from the report
Staff training
needs fixingThere was no evidence that staff had completed Mental Capacity Act and DoLS training or the recommended learning disability and autism training.
“However, there was no evidence that staff had undertaken MCA/DoLS training.” from the report
Records and medicines
needs fixingInspectors found missing or incomplete records, including minor medicines recording problems. The home was also asked to improve how it monitored accidents and incidents.
“We identified minor recording issues which the general manager told us would be addressed.” from the report
- 01What fire safety actions identified by Northumberland Fire and Rescue Authority have now been completed?
- 02Can you show us the current Deprivation of Liberty Safeguards applications and records for anyone who may lack capacity?
- 03Have all staff recruitment checks and DBS checks now been completed and recorded?
- 04What changes have been made to the systems for recording accidents, incidents, medicines and building safety checks?
- 05What action plan was sent to CQC, and what progress has been made since this inspection?
This was a focused inspection of Safe and Well-led, widened to include Effective; Caring and Responsive were not inspected during this visit, and ratings for uninspected questions were carried over from the last inspection. This explanation was written from the published report of 6 April 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 Albury House
6 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- January 2024Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Inadequate
- April 2023Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementWell-led: Inadequate
- August 2019Goodstayed GoodSafe: GoodEffective: GoodWell-led: Good
- December 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2016Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- September 2015Requires improvementSafe: InadequateEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2014
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- January 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 15 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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23 live-in carers within about an hour of Northumberland
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 £950 to £1,190 a week. 20 can care for a couple. 11 years' experience on average.
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