Ablegrange Severn Heights Limited

Updated 20 September 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 carried out by 1 inspector, 1 CQC specialist advisor and 1 Expert 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

Ablegrange Severn Heights 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. Ablegrange Severn Heights is a care home with 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 manager had been recruited and was in the process of registering with CQC.

Notice of inspection

This inspection was unannounced.

What we did before the 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. 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 used all this information to plan our inspection.

During the inspection

We spent time with people in the communal areas of the home and saw how staff supported people they cared for. We spoke with 2 people who lived at the home and 8 people’s relatives. We also spoke with 8 members of staff including the manager, clinical lead, nurse, maintenance manager, head cook and 3 healthcare assistants. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We looked at the care records for 5 people and multiple medicines records for people living in the home. We checked the care people received matched the information in their records. We looked at records relating to the management of the service, including audits, and recruitment checks carried out within service.

Updated 20 September 2023

About the service

Ablegrange Severn Heights Limited is a care home providing personal and nursing care to up to 48 people. The service provides support to older people who may live with dementia or physical disabilities. At the time of our inspection there were 16 people using the service.

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

Some improvements identified at our last inspection had been made, however further improvements were needed. People’s medicines were not always managed and administered safely and as prescribed. Environmental risks had not always been identified and addressed to ensure people’s safety. The provider’s audit and oversight systems to monitor the safety and quality of the service required further development.

Staff were recruited safely, and enough staff were employed to meet people’s needs. Staff understood and followed infection control measures, and when things went wrong, the provider had learned lessons and developed improved systems.

A positive person-centred culture was promoted, and the manager promoted learning and development. The manager and staff were caring and respectful of people which ensured a person-centred approach to the people living in the home. People’s views were sought with equality, privacy and dignity promoted.

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

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 02 February 2023).

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 some improvements had been made, however the provider remained in breach of regulations.

Why we inspected

We received concerns in relation to health monitoring. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

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 based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the Safe and Well-led sections of this report. You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Ablegrange Severn Heights on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to management of medicines, risks to people and oversight of service delivery 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 meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.