Abbeycroft Residential Care Home

Updated 5 April 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection, we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

One inspector undertook the inspection.

Service and service type

Abbeycroft Residential Care Home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Abbeycroft Residential Care Home is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced on the first day.

What we did before the inspection

We reviewed information, we had received about the service, such as notifications. These are events that happen in the service that the provider is required to tell us about. We also sought feedback from the local authority.

The provider completed a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We observed how staff provided support for people to help us better understand their experiences of the care they received. We spoke with 7 people living in the home, 3 members of staff, the compliance manager, the deputy manager and the registered manager. We also spoke with the nominated individual over the telephone and received feedback from a visiting healthcare professional and 6 relatives as part of a remote monitoring activity. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

We had a tour of the building with a member of staff and reviewed a range of records. This included 2 people’s care documentation, 2 staff files and 10 people’s medicines records. We also reviewed a range of records relating to the management of the service as well as policies and procedures.

Updated 5 April 2023

About the service

Abbeycroft Residential Care Home is a residential care home providing accommodation and personal care for up to a maximum of 33 people. The service specialises in providing care for older people and people living with dementia. There were 28 people living in the home at the time of the inspection.

People’s experience of using this service and what we found

We found shortfalls during the inspection in respect to the management of risk and the governance systems.

People told us they felt safe living in the home, and they were mostly satisfied with the service provided. Staff understood how to protect people from harm or discrimination and had access to safeguarding adults’ procedures. There were sufficient staff deployed to meet people’s needs, however, a dependency tool was not used to monitor the level of staffing. The provider had an appropriate procedure for the recruitment of new staff. Whilst individual risks to people’s health and wellbeing had been assessed, environmental risks had not always been considered. We observed some areas of the home would benefit from redecoration and refurbishment. Not all areas of the home had a satisfactory standard of cleanliness. The registered manager took immediate action to address the hygiene issues. The provider had suitable arrangements for the management of people’s medicines, however, there were omissions in the administration records for prescribed creams.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

The management team carried out a series of audits to check and monitor the quality of the service. This included a monthly analysis of accidents and incidents. However, action plans had not been developed to address any shortfalls. There were limited opportunities for people to express their views. There were no records of residents’ meetings and although people had been invited to complete a satisfaction questionnaire, the results had not been collated.

The registered manager and nominated individual were committed to making improvements to the service and had plans to improve the standards in the home. Following the inspection, the registered manager sent us a detailed action plan in response to the findings of the inspection. We will check any improvements on our next inspection of the home.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at the last inspection

The last rating for the service was requires improvement (published 19 August 2020). This service has been rated requires improvement for the last four consecutive inspections.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We have found evidence that the provider needs to make improvements. You can see what action we have asked the provider to take at the end of this full report.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to the management of risks and the governance systems. Please see the action we have told the provider to take at the end of this report.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has remained requires improvement. This is based on the findings of this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Abbeycroft Residential Care Home on our website at www.cqc.org.uk.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.