Abbeywood House

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

The key question of well-led was rated requires improvement at our last inspection. At this assessment we found improvements had been made and the service was no longer in breach of regulation relating to notification of incidents. We found the manager understood their responsibilities in relation to the duty of candour and the service had improved in notifying the Care Quality Commission without delay of incidents and injuries which had occurred, in line with their legal responsibilities. We found leaders were receptive to feedback and wanted to improve the service. However, we found a continued breach in Regulation 17 related to good governance. The provider failed to effectively operate systems to assess, monitor and improve the safety and quality of the service. The key question of well-led remains requires improvement.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

All staff we spoke with were positive about the leadership at the service. Staff told us they felt listened to and all said they were very well supported in their roles by an approachable management team. One staff member commented when asked if they were supported, “Very much so, they [meaning managers] are very nice people.” All staff said they would recommend the service as a good place to work. The management team were passionate about improving the service and recognised that there were areas that still needed further improving.

The provider had recently employed a new manager; people were positive about the improvements and communication since the new manager had come in to post. A relative told us, “Interaction with the residents has definitely improved”. At our assessment, we found the management team led with integrity, openness and honesty and were embedding this through-out the service. The management team told us they were being supported by the provider and the staff spoke about the provider being in the service most days. The service did not have a manager registered with the Care Quality Commission at the time of the assessment. A manager had been appointed by the provider to oversee the management of the service. At the time of the assessment, the service had not submitted an application to register the manager with the Care Quality Commission. This provider is required to have a registered manager to oversee the delivery of regulated activities at this location.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The manager told us, and staff confirmed that spot checks were completed at all times throughout the day, night weekdays and weekends to ensure the service was running safely and effectively. The management team told us they had regular meetings about the safety and quality of the service. However the provider was not able to provide us with any records to demonstrate this.

We found audit systems to assess, monitor and improve the safety and quality of the service were not fully effective. We found some audits were in place. However, they had not identified shortfalls found throughout this assessment. Where some audits had identified shortfalls, there was no evidence that action had been taken to prevent these shortfalls from continuing. The service failed to comply with its own policy around the management of medicines which put people at an increased risk of avoidable harm. This contributed to a continued breach of regulation 12 of the Health and Social care Act 2008 (Regulated Activities) Regulations 2014.

People living at the service and their relatives told us the service will work with professionals to improve their quality of life. We observed one person asking to go out, and the service supported that person to access the community.

The management team told us they were working with the local authority to improve the service. We witnessed the management team seek support from this team on both days of our onsite assessment. The manager was open, honest and responsive to the feedback.

At the time of our assessment the service was working closely with the local quality assurance team. Partners were positive about the responsiveness and dedication of the service to strive for improvements.

The provider had systems and processes in place to work in partnership with health partners, social services, and the local authority. The provider had contacted other services to gain additional support for the new manager. However prior to the service working with the local quality assurance team due to safeguarding concerns the provider did not instigate joint working.

We spoke with staff about learning and improving care. Staff told us about recent training they had following concerns raised by the management team to the local authority safeguarding team. Records showed an increase in training and additional training outside of their mandatory training had taken place, and further training had been booked.

The service had started to put systems and processes in place to continuously learn, innovate and improve. They had started to ensure relatives and staff were asked for their feedback and the service had started to analyse and action this feedback. However, the people using the service and professionals feedback had not yet been gained. The provider had not analysed incidents and accidents to identify themes or trends putting people at risk of avoidable harm.