CQC report explained · a nursing home
What the CQC found at West Abbey
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that risks, medicines, staffing, recruitment, safeguarding, infection control, fire safety and the environment were managed safely.
- Effective?
- Good
- This key question was not inspected during this focused visit. Its previous rating was used when calculating the overall rating.
- Caring?
- Good
- This key question was not inspected during this focused visit. Its previous rating was used when calculating the overall rating.
- Responsive?
- Good
- This key question was not inspected during this focused visit. Its previous rating was used when calculating the overall rating.
- Well-led?
- Good
- Inspectors found positive leadership, regular quality checks, clear staff roles and good communication. People, relatives and professionals gave positive feedback about how the home was run.
What inspectors found, March 2023
West Abbey is rated Good; inspectors found safe care and strong management, with the overall rating improved from Requires Improvement.
This was an unannounced focused inspection on 7 and 9 March 2023. Two inspectors and an Expert by Experience spoke with people, relatives, staff and health professionals. They reviewed care records, medicines records, recruitment files and management checks.
The home was rated Good for Safe and Well-led. Inspectors found that risks, medicines, staffing, recruitment, safeguarding, infection control and the environment were managed safely. People and relatives said they were happy with the home, which was described as friendly and welcoming.
Only Safe and Well-led were inspected. The other key question ratings were carried forward from the previous inspection when calculating the overall rating. The overall rating changed from Requires Improvement to Good.
Safe medicines
Medicines were administered and stored safely. Records and protocols were in place for medicines given when needed.
“Medicines were stored securely and temperatures of medicines storage areas were monitored.” from the report
Staffing and recruitment
The home was not using agency staff and inspectors found staffing levels were monitored against people's needs. Recruitment checks were completed.
“The service was not using any agency staff. Staff knew people well and were observed being attentive to people’s needs.” from the report
Positive atmosphere
People, relatives and professionals described the home as friendly, welcoming and well managed. Inspectors saw staff engaging with people and activities taking place.
“The home was friendly and welcoming, with a positive atmosphere.” from the report
Quality monitoring
The home used audits and feedback to monitor care and identify improvements. Staff had clear roles and systems for sharing important information.
“Systems were in place to monitor and assess the quality and safety of the service.” from the report
Involving families
Meetings allowed people, relatives and staff to give feedback. The report says this had influenced activities and food choices.
“There were regular meetings for people, relatives and staff to give feedback and be involved with how the service operated.” from the report
Inspectors raised no specific concerns in this report.
- 01What were the ratings for Effective, Caring and Responsive at the previous comprehensive inspection?
- 02What improvements have been made in those three areas since the last comprehensive inspection?
- 03How do you check that staffing levels continue to match each person's needs?
- 04How are medicines given when needed, and how do you check that records remain complete and accurate?
- 05How will relatives continue to give feedback and see what changes result from it?
This was a focused inspection of Safe and Well-led only; the other key question ratings were carried forward from the previous inspection when calculating the overall rating. This explanation was written from the published report of 28 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, February 2022
Inspected but not rated; inspectors found strong infection controls, with visiting rules due to change shortly after the visit.
This was an unannounced, targeted inspection on 17 January 2022. Inspectors were checking infection prevention and control because of concerns about visiting arrangements. They also asked about staffing pressures linked to COVID-19.
Inspectors were assured that the home was managing infection risks. They found suitable testing, personal protective equipment, cleaning, hand sanitiser, social distancing and arrangements for isolating people if needed. The home also supported visits, including visits for people receiving end of life care.
At the time of the visit, each resident could have one essential care giver and one other named visitor. This was fewer than the government guidance of up to three visitors. The provider had told relatives that its policy would change on 24 January 2022.
The home was inspected but not rated. This was not a full assessment of all five areas of care, so the report does not give an overall quality rating.
Infection prevention
Inspectors were assured that the home was taking steps to prevent visitors and residents from catching and spreading infections.
“We were assured that the provider was preventing visitors from catching and spreading infections.” from the report
Clean environment
The home was described as clean and uncluttered. Cleaning schedules were in place and checked regularly.
“The home was light, airy, uncluttered and visibly clean throughout.” from the report
Visiting support
The home provided a separate visiting suite for additional or non-vaccinated visitors and supported visits for people receiving end of life care.
“West Abbey facilitated additional visitors and non-vaccinated visitors using a comfortable visiting suite.” from the report
Testing and PPE
Staff, agency staff, contractors and the hairdresser took part in regular testing. PPE was available in large quantities.
“West Abbey had large quantities of Personal Protective Equipment (PPE) for visitor and staff use.” from the report
Visitor limits at the time
needs fixingOn the inspection date, the home allowed one essential care giver and one other named visitor for each resident. This did not match the government guidance of up to three visitors, although the provider had said its policy would change on 24 January 2022.
“Whilst this was not in line with government guidance which states: "every care home resident can nominate up to 3 visitors” from the report
- 01What are the current visiting limits, and do they now follow the policy change planned for 24 January 2022?
- 02How are additional visitors and non-vaccinated visitors supported now?
- 03How are staffing pressures linked to COVID-19 being managed?
- 04How often are staff, agency staff and residents tested?
- 05What arrangements are used if someone needs to isolate or if there is an outbreak?
This was an unannounced targeted inspection of infection prevention and control, with questions about staffing pressures; it was not a full inspection and the service was not rated. This explanation was written from the published report of 10 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 West Abbey
5 rated inspections over 8 years: the service has held its Good rating throughout.
- March 2023Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2022Inspected but not ratedSafe: Inspected but not rated
- June 2021Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- April 2020Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- August 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2015GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- January 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- March 2011
Report published without a new overall rating.
- February 2011
Registered with the Care Quality Commission on 15 February 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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