CQC report explained · a nursing home
What the CQC found at Allenbrook Home (Halesowen)Ltd
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, April 2023
Allenbrook Home (Halesowen)Ltd was rated Good; inspectors found safe, effective and well-led care, with some further improvement needed in medicines records.
This was an unannounced focused inspection. Inspectors visited on 9 February 2023 and reviewed documents remotely until 17 February. They spoke with people, relatives and staff, and checked care records, medicines records, training, incidents, complaints and quality checks.
The home was rated Good for Safe, Effective and Well-led. Inspectors found that risks were assessed, medicines were generally managed safely, there were enough staff, people had access to healthcare, and staff were trained and supported. People and relatives gave positive feedback about safety, food, the environment and management.
The previous rating was Requires Improvement, published in November 2019, with a breach of regulation. Inspectors found that improvements had been made and the home was no longer in breach. The overall rating changed to Good.
Protection from abuse
People and relatives said they felt safe. Staff had safeguarding training and safeguarding concerns were reported when required.
“People told us they were cared for in a safe and respectful way.” from the report
Staffing and recruitment
Inspectors found enough staff to meet people's care needs and saw that recruitment checks were completed. Agency staff were checked before working in the home.
“There were enough staff to ensure people's care needs could be safely met.” from the report
Health and nutrition
People had access to healthcare professionals and staff monitored their health. Food, drinks and specialist diets were provided according to people's needs.
“People had full access to healthcare services.” from the report
Management culture
The home had quality monitoring systems and staff said managers were approachable and listened to them. Relatives also reported confidence in the management.
“The positive culture of the home showed the provider's values had been embedded, and staff and management we spoke were open and transparent.” from the report
Handwritten medicines records
needs fixingSome medicines administration records were handwritten and not always easy to read. Inspectors said this increased the risk of medicines errors, although the manager acted promptly by contacting the pharmacy for printed records.
“People's medication administration records (MAR) were handwritten and the instructions on these were not always easily readable.” from the report
Use of agency staff
minorThe home was using agency staff to cover current staff shortages. Inspectors found the required checks were completed and said staffing levels were safe at the inspection.
“The provider used agency staff to cover current staff shortages.” from the report
Timing of feedback surveys
minorThe director identified that surveys were sometimes sent at unsuitable times, which could reduce the response received. The timing was due to be changed.
“The director identified that the timing of sending out surveys was to be amended as certain months, for example December, were not effective points during which to gain a full response.” from the report
- 01Have the handwritten medicines administration records been replaced with printed records, and how do you check that instructions remain clear?
- 02How many agency staff are currently working in the home, and how do you maintain consistency for residents?
- 03What changes have been made since the inspection to address the staff shortages?
- 04How will you make sure feedback surveys are sent at times when people, relatives and staff can respond?
- 05What were the most recent ratings or findings for Caring and Responsive, which were not inspected during this visit?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and their ratings were carried over from the last inspection. This explanation was written from the published report of 4 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.
What inspectors found, February 2022
Allenbrook Home (Halesowen)Ltd was inspected but not rated; inspectors found good infection control, with a record-keeping gap about visiting professionals' vaccination status.
This was an announced, targeted inspection on 10 February 2022. CQC looked at infection prevention and control, visiting arrangements, and whether COVID-19-related staffing pressures were affecting the home.
Inspectors found that staff used protective equipment correctly. The home had cleaning schedules, testing and vaccination monitoring, and arrangements to support visits. They were assured that infection risks were being managed in the areas they checked.
There was one record-keeping problem. The manager could not find the evidence showing that visiting professionals' vaccination status had been checked. A chart was provided after the inspection, and the recording system was changed from paper to electronic during the inspection.
The service was inspected but not rated. This means the inspection did not give an overall quality rating or a rated judgement for the areas checked.
Infection control
Inspectors were assured that the home had arrangements to prevent and manage infections, including testing, PPE and an up-to-date policy.
“We were assured that the provider's infection prevention and control policy was up to date.” from the report
Clean environment
The home had regular cleaning schedules and was visibly clean and uncluttered.
“The home was visibly clean and free of clutter.” from the report
PPE use
Staff had access to PPE and inspectors saw it being worn correctly in line with government guidance.
“Staff had access to personal protective equipment (PPE) and were observed to wear this correctly and in accordance with current government guidelines.” from the report
Visiting arrangements
Visiting was promoted, with testing, temperature checks and PPE available. Visitors could see their loved ones in a place suited to the individual.
“Visitors were able to see their loved ones where it was most comfortable for the individual.” from the report
Vaccination records
needs fixingThe manager said visiting professionals' vaccination status was checked, but the evidence could not be found during the inspection. A chart was supplied afterwards and the system was changed to electronic recording.
“they were unable to locate the folder containing the evidence of this during the inspection.” from the report
- 01How does the new electronic system record and check the COVID-19 vaccination status of visiting professionals?
- 02Can you show us how you make sure visiting professionals provide vaccination evidence before entering?
- 03How are current staffing pressures affecting care and support for residents?
- 04How are visits arranged now, and what testing or PPE is required?
- 05What changes have been made since the inspection to infection prevention and control arrangements?
This was a targeted inspection of infection prevention and control, visiting arrangements and COVID-19-related staffing pressures; the service was inspected but not rated and the other key questions were not assessed. This explanation was written from the published report of 26 February 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 Allenbrook Home (Halesowen)Ltd
2 rated inspections over 3 years: the service has improved, from Requires improvement to Good.
- April 2023Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Allenbrook Home (Halesowen)Ltd →
- February 2022Inspected but not ratedSafe: Inspected but not rated
Read what inspectors found at Allenbrook Home (Halesowen)Ltd →
- November 2019Requires improvementSafe: Requires improvementEffective: GoodWell-led: Requires improvement
- October 2018
Registered with the Care Quality Commission on 22 October 2018.
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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