CQC report explained · a residential care home
What the CQC found at The Abbeys
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, March 2021
The Abbeys was inspected but not rated; inspectors were assured about infection prevention and control, with some shower rooms awaiting refurbishment.
This was a targeted, announced inspection on 12 February 2021. It looked only at infection prevention and control during the coronavirus pandemic.
Inspectors were assured that the home used personal protective equipment safely, followed social distancing and shielding rules, carried out testing, and kept its infection control policy up to date.
The home had arrangements for relatives to visit safely, including a visiting pod and screened areas. Staff also provided extra activities to help prevent social isolation.
The home was clean overall, although inspectors noted that some shower rooms needed attention. These were due to be refurbished, with additional en-suite facilities planned. The service was inspected but not rated, so this report does not give a full quality rating.
Infection control
Inspectors were assured that the home had measures to prevent and manage infection, including safe use of protective equipment and regular testing.
“We were assured that the provider was preventing visitors from catching and spreading infections.” from the report
Safer visits
The home had several visiting arrangements designed to reduce infection risk, including a separate visiting pod that was cleaned between visits.
“The provider had recently installed a visiting pod, the pod was segregated with separate entrances for people and their relatives.” from the report
Activities and wellbeing
Staff had put extra activities in place to help reduce social isolation during the pandemic.
“The registered manager and staff had considered how to prevent social isolation during the pandemic.” from the report
Staff preparation
Staff had training in infection control, coronavirus and using protective equipment. They were also briefed about changes to government advice.
“Staff had completed training in infection control, COVID-19 and how to put on and take off their PPE.” from the report
Shower rooms
minorInspectors said some areas needed attention, particularly the shower rooms. The home had identified this and planned a full refurbishment, including additional en-suite facilities.
“There were areas that required attention. For example, shower rooms, these had been identified as part of the providers quality monitoring and were due to be completely refurbished, including installing additional en-suites.” from the report
- 01What progress has been made with the planned shower room refurbishment and additional en-suite facilities?
- 02How are visits arranged now, and is the visiting pod still available and cleaned between visits?
- 03How does the home provide activities and support to prevent people becoming socially isolated?
- 04How often are staff tested and updated about infection prevention and control procedures?
- 05What arrangements are in place if there is an infection outbreak?
This was a targeted inspection of infection prevention and control during the coronavirus pandemic; it did not provide ratings for the other areas of care. This explanation was written from the published report of 6 March 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.
What inspectors found, November 2018
The Abbeys was rated Good; inspectors found kind, safe care and clear improvements since the previous inspection.
Inspectors visited without warning on 25 October 2018. They looked around both buildings, spoke with people living there, relatives, staff and visiting health professionals, and reviewed care plans, medicines, recruitment, training, complaints and management records.
All five areas were rated Good: safe, effective, caring, responsive and well-led. Inspectors found enough staff, safe medicines arrangements, suitable care plans, good support with food and health needs, kind staff and a varied activities programme.
The previous inspection in November 2017 rated the home Requires Improvement because some records lacked enough information. This inspection found that care records and records of best-interest decisions had improved. The home was rated Good overall.
Kind and respectful care
Staff were compassionate and patient. Inspectors saw positive interactions and found that privacy, dignity and personal choices were respected.
“Throughout the day we observed numerous positive interactions between people who used the service and staff, who were appropriately affectionate and respectful.” from the report
Improved care records
Care plans gave clearer guidance about people's needs, risks, preferences and safe movement. This addressed a concern from the previous inspection.
“At this inspection care records had been improved and contained appropriate information about people's needs, including how to move them safely using a hoist.” from the report
Safe staffing and medicines
There were enough staff on duty during the visit, call bells were answered promptly and medicines were stored and administered safely.
“Medication administration records [MAR] checked had been completed correctly and stock sampled tallied with the records.” from the report
Good support with food and activities
People were offered a varied diet and choice at mealtimes. Inspectors also found a varied programme of social activities, including group and one-to-one activities.
“People had access to a varied programme of social activities, which they enjoyed.” from the report
Open management
The manager was visible and approachable. People, relatives and staff were encouraged to give feedback and raise concerns.
“The service had an open and positive culture that encouraged involvement of people using the service, their families and staff.” from the report
Minor medicines recording errors
needs fixingA pharmacy audit had found a few gaps in medicines administration records. The manager said these had been addressed, but families may want to ask how this is checked now.
“At their visit on 16 October 2018 they had highlighted minor errors, such as a few gaps in MAR, however, the registered manager told us these had been addressed.” from the report
One incomplete recruitment file
minorOne staff file contained only one written reference. A verbal reference had been recorded and a written reference was being followed up.
“However, we noted one file only contained one written reference.” from the report
Audit action dates
minorNot all individual audits stated when identified actions should be completed. The manager said this would be recorded in future.
“However, we found not all individual audits identified timescales for completion.” from the report
Food allergen information
needs fixingThe Food Standards Agency had said improvement was needed in the kitchen's information about allergens. The report says action had been taken and information was displayed around the home.
“In June 2018 the Food Standards Agency had assessed the kitchen facilities and documentation at the home and found improvement was needed.” from the report
- 01How do you now check that every medicines administration record is complete after the gaps found in the pharmacy audit?
- 02Has the missing written reference in the recruitment file now been obtained and checked?
- 03How do you record deadlines and follow up actions identified in individual audits?
- 04How do you give residents and families information about allergens in meals?
- 05How are care plans reviewed when a person's needs or risks change?
This was an unannounced comprehensive inspection covering all five rating areas, including the care and premises of both buildings. This explanation was written from the published report of 16 November 2018 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 The Abbeys
4 rated inspections over 3 years: the service has improved, from Requires improvement to Good.
- March 2021Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- November 2018Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2017Requires improvementstayed Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Good
- October 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- February 2016Requires improvementSafe: Requires improvementEffective: GoodCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- April 2015
Registered with the Care Quality Commission on 7 April 2015.
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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