Abbotsfield Hall Residential Home

Abbotsfield Hall Residential Home (thereafter referred to as Abbotsfield Hall) is a residential care home providing personal care for older people. Abbotsfield Hall is registered to accommodate 28 people, at the time of the inspection 18 people lived at the service.

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

People told us they felt safe living at Abbotsfield Hall. The registered manager and staff knew how to protect people from the risk of harm or abuse. There were enough numbers of staff available to meet people’s needs. Staff were recruited safely and received an induction and training to ensure they could meet people’s health and care requirements.

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

People received their medicines as prescribed and systems were in place to receive, store and manage medicines safely. Staff followed infection control guidance and had access to Personal Protective Equipment (PPE).

We have made a recommendation about the further development of care records.

Staff understood their roles and responsibilities. Staff liaised with health and social care professionals to ensure people’s health and care needs were met. The provider carried out regular audits of the service to oversee the quality of the care provided to people.

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

Rating at last inspection

The last rating for this service was requires improvement (published 22 October 2021).

The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

We carried out an unannounced inspection of this service on 26 and 27 August 2021. A breach of legal requirements was found. The provider completed an action plan after the last inspection to show what they would do and by when to improve good governance. We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements.

This report only covers our finding in relation to the Safe and Well-led key questions, which contain those requirements. 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 changed from requires improvement to good, based on the findings of this inspection.

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.

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

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Abbotsfield Hall Nursing Home (“Abbotsfield”) is a residential care home providing personal and nursing care to up to 28 people aged 65 and over. At the time of the inspection the service was supporting 17 people.

Abbotsfield accommodates people within a building converted to meet people’s needs.

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

Following our previous inspection, the registered manager and provider had ensured many areas of concerns were addressed. However, we continued to have concerns that systems and processes were not always effective in demonstrating people’s records were complete or the service was being reviewed to ensure the quality was good. We also identified that some risks and health needs were not sufficiently planned for.

People told us they were happy, safe and well cared for by staff. People and relatives felt staff were caring and we observed staff treating people with dignity and respect during the inspection. Staff told us they felt their training, supervision and support was good. They told us how they cared for and would act to ensure people were safeguarded if needed. Staff also demonstrated how they understood people and their needs. We found information was not always passed on to staff to ensure people’s needs were met.

People, relatives and staff spoke positively about the management and felt there was good communication. Relatives were being supported to visit safely and communicate with their loved ones living in the service.

The home was clean, and staff were ensuring they followed Covid 19 guidelines. People’s medicines were safe. There was sufficient staff to meet people’s needs and, these were recruited safely.

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

Rating at last inspection Following an inspection from the 28 September to 15 October 2020 ("our 2020 inspection"), we rated the service Inadequate (published 3 March 2021). There were multiple breaches of regulation. We placed conditions on the provider and registered manager’s registrations. They have provided a report each month on their improvement program

In March 2021, we carried out a targeted, unrated inspection to look at specific risks (published 10 April 2021). We found no concerns in respect of the risks however, we served a warning notice due to concerns about their infection prevention and control (IPC) measures. We reviewed the homes IPC processes during this inspection.

This service has been in Special Measures since 2 December 2020. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This was a planned inspection based on the previous rating.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contained those requirements.

The ratings from the previous comprehensive inspection for those key questions, not looked at on this occasion, were used in calculating the overall rating at this inspection. The overall rating for the service has changed from Inadequate to Requires improvement. This is based on the findings at this inspection.

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

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.

We have found evidence that the provider needs to continue to make improvements. Please see the safe and well-led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

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 have identified a breach in relation to how the registered manager and provider were ensuring system and process were in place and used to improve the service and keep people safe at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan for 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Abbotsfield Hall Nursing Home (hereafter referred to as Abbotsfield) is a nursing home providing personal and nursing care to 16 people aged 65 and over. The service is registered to support up to 28 people, some of whom are living with a dementia.

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

People were not always protected from the risk and spread of infection. We were not assured that Infection Prevention and Control (IPC) practice was safe and the service was compliant with IPC measures. This was communicated at inspection and the provider and registered manager was supported to take immediate and appropriate action to address the concerns.

Personal protective equipment (PPE) was readily available. However, staff were not always wearing PPE safely and in line with current guidance. We observed staff not always wearing the correct fluid resistant masks, wearing it in the correct way or wearing a face covering at all.

Risks in relation to skin care were assessed, and measures were taken to mitigate these. For example, pressure relieving equipment was in place, staff checked people’s skin for skin damage and people were helped to change position regularly to protect vulnerable skin.

Whilst we did not identify any specific concerns in relation to people’s skin care, records were not always thoroughly completed to show that action that had been taken to mitigate and manage the risk. The provider, registered manager and clinical lead were aware of the concerns regarding record keeping and were working with the local authority to make the necessary changes.

People were supported to eat and drink enough to maintain their health and reduce the risk of dehydration and malnutrition. Staff were aware of people's dietary risks and needs and were following the eating and drinking support plans that had been put in place. Where people were at risk of losing weight, staff monitored people’s weight monthly and action was taken if people had lost weight. People told us they were happy with the food at the service, had enough to eat and drink and received the support they needed to eat their meals.

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

Rating at last inspection

The last rating for this service was inadequate (published 2 March 2021).

Why we inspected

The inspection was prompted due to concerns we received about risks associated with skin care and nutrition and hydration. A decision was made for us to undertake a targeted inspection examine those risks.

CQC have introduced targeted inspections to check specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

We also 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 coronavirus and other infection outbreaks effectively.

We have found evidence that the provider needs to make improvements. Please see the safe section of this report.

You can see what action we have asked the provider to take at the end of this full report.

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 have identified a breach in relation to infection prevention and control 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.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Abbotsfield Hall Nursing Home (hereafter referred to as Abbotsfield) is a nursing home providing personal and nursing care to 22 people aged 65 and over at the time of the inspection. The service is registered to support up to 28 people and supports older people, some of whom have nursing needs and some of whom are living with a dementia. The service is located in Tavistock in Devon and is a building over three floors set in its own grounds. The service has a lift, chair lifts, a separate dining room and two communal lounges.

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

Prior to this inspection we received information of concern regarding the safe care and treatment of people and we decided to inspect. The local safeguarding authority placed the service in to the whole home safeguarding process as there were significant safeguarding concerns. Investigations in to safeguarding allegations were ongoing during our inspection. Due to the quality concerns raised, the local authority provided support to the service from Devon’s quality in care homes team. The provider also voluntarily suspended further placements in to the service as a way to mitigate further risk.

People told us they felt safe. However, we found several allegations of abuse had not been actioned appropriately, reported to the local safeguarding authority or notified to us. Although staff had completed safeguarding training, there was a failure on the part of the provider and registered manager to put systems in place. This meant some people experienced improper care and treatment.

Improvements were needed to the way medicines were managed. Some risks people faced in relation to their needs were not assessed. For several people, records relating to risk, incidents and care planning were out of date, had not been completed or had key information missing. Some risks that had been identified did not have clear instruction for staff on how to support people with that risk. This placed people at risk of not having safe care and treatment.

Systems and processes were not robust to check care delivery was safe, of high quality and consistent. Records to show care delivery were often poorly filled out. There was a lack of accountability from service leadership for the failure to complete audits in key areas such as infection control and care planning.

People were supported to have choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests. However, the policies and systems in the service needed to be reviewed. Systems and processes to protect people and their rights were not always robust.

We saw some evidence to suggest there were not enough staff on shift or they were not deployed effectively during the shift to ensure people’s needs were met. Staff were not always recruited safely, and some information was missing from recruitment files that was important in checking whether potential staff were suitable to work with people who might be vulnerable.

Staff told us they felt supported. However, we found formal supervisions were not taking place and interactions with staff where support was offered were often not recorded. Feedback we received about staff was that they were kind and caring and “did their best.”

Feedback from professionals was that some positive health outcomes were being achieved for people living in the service and care staff were willing to learn. People and relatives gave positive feedback about staff and the care their loved one was receiving.

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

Rating at last inspection

The last rating for this service was good (published 27 September 2018).

Why we inspected

We received information in relation to the management of safeguarding concerns and the culture of the service. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

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.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from good to inadequate. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvement. Please see the safe and well-led sections of this report.

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 discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to safeguarding, safe care and treatment, staffing, recruitment, good governance and making notifications to us.

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.

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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The overall rating for this service is ‘Inadequate’ and the service is therefore 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 timeframe and there is still a rating of inadequate for any key question or overall rating, we will act 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.

Abbotsfield Hall Nursing Home provides accommodation and nursing care for a maximum of 28 older people. There were 22 people using the service at the time of this inspection. One person was staying at the service for a period of respite (planned or emergency temporary care provided to people who require short term support), although they were in hospital at the time of our visit.

Abbotsfield Hall Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. The service is located on the outskirts of Tavistock and is a detached period property. The home consists of three floors with the ground and first floor used for accommodation with a passenger lift providing access to the first floor. There are two large communal lounges and a large dining area. There is a large well-maintained garden which people have access to. People could choose where they spent their time.

At our last comprehensive inspection in August 2017 the service was rated requires improvement overall. We issued the provider with three requirements, which identified the following areas to be improved.

These were because:

• The provider had not ensured that care and treatment was provided in a safe way.

• They had not assessed the health and safety risks to people.

• The premises were not always safe.

• Medicines were not safely managed.

• They did not have systems and processes which were effective and established and operated effectively to assess, monitor

and improve the quality and safety of the services provided.

• The provider has legal obligations to submit statutory notifications when certain events, such as a death or injury to a person occurred.

These had not always been submitted.

Following the inspection, we were sent an action plan which set out the actions the provider was going to take. The provider also worked with the local authority Quality Assurance and Improvement Team (QAIT) to help support them put new processes in place. This included a service improvement plan setting out the actions required, who would undertake them and the time scales. At this inspection we found the provider had made the improvements and were no longer in breach of these regulations.

There was a registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The registered manager had been registered with CQC on the 8 August 2017.

The registered manager had implemented several assurance systems to assure themselves the service was running safely. They had developed a service improvement plan (SIP) and were working through the actions. The providers regularly visited the service and were kept informed about the running of the service.

People said they felt safe and cared for in the home. People were protected from unsafe and unsuitable premises. Risks for people were reduced by an effective system to assess and monitor the health and safety risks at the home. Staff were able to record repairs and faulty equipment in a maintenance log and these were dealt with and signed off by the maintenance person.

People’s needs were assessed before admission to the home by the registered manager and these were reviewed on a regular basis. Risk assessments were undertaken for all people to ensure their individual health needs were identified and met.

The provider submitted statutory notifications as required and provided additional information promptly when requested. The provider had displayed the previous CQC inspection rating at the service in accordance with the regulations.

There were sufficient and suitable staff to keep people safe and meet their needs. Thorough recruitment checks were carried out. New staff received an induction that gave them the skills and confidence to carry out their role and responsibilities effectively. The registered manager had been working with staff to complete the provider’s mandatory training. People were protected from the risks of abuse as staff understood and knew how to report any concerns.

Improvements had been made to the medicine management at the home. A safer system to ensure the safe management of medicines at the service had been implemented. Medicines were administered by registered nurses who had been trained regarding medicine management and had their competency checked. The registered manager was working with the local GPs and pharmacist to improve the instructions of prescribed creams to guide staff.

Staff had the skills and knowledge to support people appropriately. Since our last inspection, they had received regular supervision and appraisals to support them with their performance and future development. When they started working at the service new staff undertook a thorough induction. Staff new to care were supported to complete the Care Certificate a nationally recognised qualification based on best practice. The registered manager undertook relevant professional registration checks to ensure nurses were registered with the Nursing Midwifery Council (NMC).

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. Capacity assessments were undertaken and best interest decisions were being recorded. This helped to protect people’s rights.

People were supported to have a balanced and variable diet. Where people had specific dietary requirements, these were catered for.

People had access to health professionals. They said they had a good working relationship with the staff and the system worked well.

Staff were caring and kind. They treated people with respect and dignity. There was a friendly atmosphere at the home and a strong ethos from all staff regarding it being a family and people’s home. The registered manager and staff were committed to ensuring people experienced end of life care in an individualised and dignified way.

There was a designated activity staff member to support people to engage in activities that they were interested in, on an individual and group basis. There were regular outings to places of interest in conjunction with a local organisation.

People knew how to make a complaint if necessary. They said if they had a concern or complaint they would feel happy to raise it with the management team.

We last inspected the home in July 2015 when the service received an overall rating of ‘Good’. However on that occasion we rated the safe domain as ‘requires improvement’ because of medicine management, although there were no breaches of regulation.

Abbotsfield Hall Nursing Home provides accommodation and nursing care for a maximum of 28 older people. There were 23 people using the service at the time of this inspection; 14 people were having their nursing needs met by the nurses employed at the service. The remaining nine people had residential needs and had their nursing needs met by the community nurse team.

There was a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The registered manager had been registered with CQC on the 8 August 2017.

People were positive about the care they received at Abbotsfield hall. Comments included, “I am quite safe in here” and “You ain’t going to get any better than you get here.”

However, on the first day of our inspection we identified some risks which could mean people were not safe. People were not always protected from the risks of unsafe unsuitable premises. This was because not all of the windows above the ground floor were restricted and hot water temperatures from people’s taps were above the recommended level. Portable radiators were used in people’s rooms which had not been PAT tested (portable appliance testing). Risk assessments had not been completed to assess the level of risks to individuals. A fire door was held open with a bottle of detergent. We wrote to the provider after the first day of our inspection identifying the concerns we had found. The registered manager sent us a response on behalf of the provider giving us assurances about what actions they had or would be taking to resolve the concerns identified. On the second day of our visit we found actions had and were being taken to keep people safe.

Staff recorded accidents promptly in the accident book and the actions they had taken at the time. However, there was no regular monitoring of accidents and incidents at the service to look for patterns and trends and ensure that staff were responding appropriately and risks reduced, where possible. We raised with the providers that the security to protect people from intruders was poor. They said they would review their systems.

Medicines were not always being safely managed in particular prescribed creams. Improvements were being implemented by the registered manager, which included a body map to guide staff where to administer creams and to sign when they had completed this task.

There were adequate numbers of staff on duty although concerns were raised regarding the staffing levels during the evening. The registered manager was undertaking a second dependency tool assessment to assure themselves that staff were deployed at the appropriate times to meet people’s needs. They said they would adjust the staffing level if required.

Staff were friendly and kind to people and wanted to provide a good service. They treated people with dignity and supported them to make daily choices about the care they received. The provider had a computerised care record system which not all the staff could populate with information. This was because they had only basic training on the new system. There were care plans in place but these were not always updated in a timely way. However staff were kept informed of changes in the handovers between shifts and through a communication book. Since the inspection, the registered manager and the providers have made a decision to revert back to a paper based care system. They had concluded staff were more competent at using this format. They said this transfer would be completed by the 10 October 2017.

There was no clear delegation of responsibilities about who made decisions about admissions to the service when the registered manager was on leave. Following the inspection, the registered manager said they had put in place a flow chart to guide staff about roles and responsibilities in their absence.

The provider did not have robust quality assurance procedures in place to ensure the safe running of the service. Policies and procedures and the statement of purpose had not been reviewed to ensure they reflected current guidance and best practice. Audits were not carried out regularly and action points were not monitored to ensure improvements were made.

Staff were knowledgeable about recognising the signs of abuse and had a good understanding of how to keep people safe. New staff had received an induction when they started working at the service. All staff had received training to ensure they had the right skills and knowledge to meet people’s needs. Recruitment procedures were thorough and all necessary checks were made before new staff commenced employment. Staff said they felt supported by the management team, although they had not all received a one to one supervision with their line manager.

Staff demonstrated an understanding of their responsibilities in relation to the Mental Capacity Act (MCA) 2005. They understood where people lacked capacity, a mental capacity assessment needed to be completed with best interest decisions made in line with the MCA. They had submitted applications where required to the local authority Deprivation of Liberties Safeguarding team (DoLS) to deprive some people of their liberties.

People were supported to have regular appointments with their GP, dentist, optician, chiropodist and other specialists. Health professionals said they had no concerns about the service.

Activities were available. There was a staff member designated for four hours a week to undertake one to one activities with people in their rooms to help avoid social isolation. Staff said they felt there should be more activities available to people. However people said they were happy with the activities at the service.

People were supported to eat and drink sufficient amounts to maintain their health. People had mixed views about the food at the service. Improvements were being implemented to ensure people had a greater input into deciding the menus and having a choice.

The registered manager actively sought the views of staff through regular meetings. There were limited opportunities for people and their relatives to give their views about how the service was run. There had been two complaints made at the home in the last year which had been responded to appropriately.

The provider is required by law to send CQC notifications about important events at the service. For example, deaths, serious injuries or safeguarding concerns. We had not received any notifications as required from the provider since January 2017. Since the inspection, eight have been submitted retrospectively.

We found three breaches of regulation. You can see what action we told the provider to take at the back of the full version of this report.

Relatives we spoke with were very positive about the care people received. One relative said “we left no stones unturned to ensure quality of life was as good as it could be. Staff have been very patient with the family as well, they have responded to our anxieties and helped us by pointing us in the right direction. It feels like home here; all of my family feel this”.

One person we spoke with told us “I go outside in the summer, I like to get out I have a nice room”. We saw that the home was accessible, clean and in a good state of decoration.

Staff we spoke with were clear about their role and the manager showed us recently updated job descriptions. We saw that relevant checks had been undertaken prior to staff being appointed.

We saw that the organisation encouraged feedback about the service provided. When comments were made these were listened to and actions agreed as appropriate. One relative we spoke with said “You can raise any issue you want to; there is an openness about the place”.

We saw that people were involved in decisions about their care and treatment and that they were treated with respect and kindness. The standard of personal care people received was high and health care needs were met because the staff were skilled and knowledgeable and provided in sufficient numbers. There was a good provision of equipment, the home was very clean and fresh and staff were keen to listen to what people had to say. There was a programme of entertainment and activities and staff had time to spend sitting with people. People were able to follow their faith and their independence was promoted.