Abbeyfield Loughborough

Updated 15 December 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

This inspection was carried out by 2 inspectors and 2 Experts-by-Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Abbeyfield Loughborough 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. Abbeyfield Loughborough 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 provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was not a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. The provider had not been sent a provider information return (PIR) prior to this inspection. This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We met with 6 people and 2 relatives and spoke to a further 9 relatives by telephone about their experience of the care provided. We spoke with 10 staff including the general manager, 2 assistant managers and care staff. We observed staff interactions with people whilst delivering care and support in communal areas during mealtimes, medicines administration and provision of activities.

We reviewed a range of records. This included 6 people's care records, multiple medicine records and daily care notes. We looked at 3 files in relation to the recruitment and supervision of staff. We examined a variety of records relating to the management of the service, including policies and procedures, quality assurance audits and staff training records.

Updated 15 December 2023

About the service

Abbeyfield Loughborough is a care home specialising in dementia care. The premises consist of Westfield House, the original part of the home, along with Ingleside House, a new three-storey home. The two parts of the premises are joined by a link corridor and communal garden area. The service provides accommodation and personal care for up to 64 people. At the time of our inspection, there were 57 people using the service.

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

People were at risk of harm due to a lack of staff supervision and mitigation of known risks associated with their needs. Staff lacked the knowledge, information and training to ensure the safety of people during distressed behaviours which placed them and others at risk of harm. Staff lacked the understanding and skills needed to effectively support people living with complex dementia.

Staffing levels were not sufficient to meet people's individual needs and keep them safe from harm. Additionally, people did not receive the support they needed to have enough to eat and drink or to maintain their wellbeing and hygiene. People were not consistently supported to maintain their oral hygiene and mitigate risks around oral care.

People and staff were not always protected from the risk of avoidable harm. The provider failed to have systems and processes to ensure lessons were learnt and remedial action was taken in a timely manner to keep people safe. People's medicines were not always administered or managed safely. People were protected from the risk of infections, though some areas of the premises required updating and decorating. The premises did not fully support the needs of people living with dementia.

Care planning documentation was not always detailed with information regarding people's individual needs and did not provide the guidance staff needed to deliver person centred care.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice. Consent had been given by relatives and external agencies without the legal authorisation to do so.

The providers' systems for assessing, monitoring, and improving the quality and safety of the service were not operating effectively. They failed to identify issues we found at this inspection. There was poor oversight of the service to ensure people received safe care and treatment.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 5 April 2023) and there were breaches of regulations. The provider submitted an action plan detailing what improvements they intended to make.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

Enforcement and Recommendation

We have identified breaches in relation to risk management, medicines, staffing, consent and management oversight at this inspection. Full information about CQC's regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Special Measures

The overall rating for this service is 'Inadequate' and the service is in 'special measures'. This means we will keep the service under review and, if we do not propose to cancel the provider's registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this time frame and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration. For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Abbeyfield Loughborough on our website at www.cqc.org.uk.