Abbey Grange Care Home

Updated 31 May 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

The inspection was undertaken by 2 inspectors and an Expert by Experience on day 1 of the inspection, and 1 inspector on day 2 of the inspection. 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

Abbey Grange 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. Abbey Grange 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 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. A new manager was in post and had submitted an application to register. We are currently assessing this application.

Notice of inspection

This inspection was unannounced.

Inspection activity started on 5 April 2023 and ended on 21 April 2023. We visited the location on 5 April 2023 and 6 April 2023.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We used the information the provider sent us in the provider information return (PIR). 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 sought feedback from the local authority and Healthwatch. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. We used all this information to plan our inspection.

During the inspection

We spoke with 8 people that used the service and 2 relatives. We spoke with 2 visiting professionals. We spoke with 6 staff members including the manager, care staff and the provider.

We reviewed a range of care records including 3 care plans. We looked at 3 staff files in relation to recruitment. We reviewed records relating to health and safety, medicines management, infection prevention and control, complaints, quality control and policies and procedures.

Updated 31 May 2023

About the service

Abbey Grange Care Home is a residential care home providing accommodation for people who require personal care to up to 25 people. The service provides support to older people and those living with dementia or a physical disability. At the time of our inspection there were 20 people using the service. The home is an adapted building with separate, self-contained flats.

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

People were not always supported safely. Records relating to medicines management were not always in place or were incomplete. Risks relating to the health and safety of the premises had not always been assessed or managed effectively. Staff recruitment checks were not robust and relevant checks had not always been undertaken. People we spoke to said they felt safe at the home and safeguarding referrals had been made where required.

Quality assurance systems were not always effective in the areas of medicines, health and safety and staff recruitment. The manager and provider understood the need for duty of candour and were in an ongoing process of improvement and development. People and their relatives praised the management team who were described as “Helpful” and, “Understanding.” The manager understood the importance of partnership working and we saw evidence of this during the inspection.

People’s needs were assessed but recording of people’s weights had not been completed frequently. We made a recommendation about this. Mental capacity assessments were in place but had not always been completed for different areas of people’s care. We made a recommendation about this. People spoke positively about the food and fluids they were offered and were supported by staff who had received training and regular supervision.

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 were supported by staff who respected their privacy, independence and dignity. People and their relatives spoke highly of the staff approach, and staff knew the people they supported well. There were systems in place for people to express their views on the care they received, although they were not always effective. We made a recommendation about this.

Care records were person centred and people’s communication needs were met. People were engaged in a range of activities and were supported to maintain relationships that were important to them. People we spoke to enjoyed living at the home and their relatives did not have any complaints or concerns.

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 2 November 2018).

Why we inspected

The inspection was prompted in part due to concerns received about safeguarding, medicines management and staffing issues. A decision was made for us to inspect and examine those risks.

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

Enforcement and Recommendations

We have identified breaches in relation to safe care and treatment, medicines, and good governance. We have made recommendations in relation to mental capacity assessments, gathering feedback from people and monitoring of people’s weights.

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 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.