The Abbeys

We found the following examples of good practice.

¿ People were protected against the risk of infection.

¿ The home had robust systems in place to support relatives to visit their family members, minimising the risk of infection. Visits had been facilitated at windows or in the reception area, with the use of screens. The provider had recently installed a visiting pod, the pod was segregated with separate entrances for people and their relatives. This was fitted with an intercom and was thoroughly cleaned between visits. The only exceptions to these arrangements were visits to people placed on end of life care. Visits took place by prior arrangement; relatives had a lateral flow test (LFT) and PPE was worn.

¿ The registered manager and staff had considered how to prevent social isolation during the pandemic. They had put in place additional activities to ensure peoples well-being.

¿ The provider had regularly updated policies and procedures to ensure they included changes and best practice guidance in relation to COVID-19. Staff we spoke with were knowledgeable about the updates and were working in line with them.

¿ We observed staff changed PPE, when appropriate, and washed and sanitised their hands. Staff changing facilities had been provided to minimise the risk and spread of infection.

¿ Tests for COVID-19 were being carried out in line with guidance. Staff also had regular LFT to ensure any staff who were not presenting with any symptoms were identified promptly.

¿ The premises were clean. There was a cleaning schedule in place and adequate cleaning hours to ensure it was maintained. Additional cleaning of high use areas had been implemented, including door handles, and handrails. There were areas that required attention. For example, shower rooms, these had been identified as part of the providers quality monitoring and were due to be completely refurbished, including installing additional en-suites.

¿ Staff had completed training in infection control, COVID-19 and how to put on and take off their PPE. Staff were frequently briefed about changes in government advice that impacted on their role. Staff we spoke with confirmed this.

¿ Risk assessments were in place to consider and reduce any impact to people who used the service and staff who may be disproportionately at risk of COVID-19. These included Black, Asian and Minority Ethnic groups (BAME), people with learning disabilities and people with dementia.

Further information is in the detailed findings below.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘The Abbey’s’ on our website at www.cqc.org.uk’

The Abbeys is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The Abbeys provides personal care and support for up to 80 people, this includes people living with dementia. There are 75 bedrooms in two separate buildings, the main building and Abbeydale. The home is located on the outskirts of Rotherham and has good access to local amenities and public transport links. At the time of our inspection there were 54 people using the service.

The service had a registered manager in post at the time of our inspection. 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.

Staff supported people in a compassionate, caring, responsive and friendly manner. They encouraged them to be as independent as possible, while taking into consideration their abilities and any risks associated with their care. All the people we spoke with made positive comments about how staff delivered care and said they were happy with the way the home was managed.

Systems were in place to safeguard people from abuse.

Care and support was planned and delivered in a way that ensured people were safe. Where possible, people had been involved in planning their care. Care plans outlined peoples’ needs and risks associated with their care, as well as their abilities and preferences. Since our last inspection the information in care plans about how individual people were assisted to move using a hoist had improved.

Recruitment procedures aimed to make sure staff employed were suitable to work with vulnerable people. Staff were trained and supported to develop their skills, so they could provide people with the standard of care they required. There was enough staff on duty to meet the needs of the people living at the home at the time of our inspection.

Medication was managed safely and administered by staff who had completed training to carry out this role.

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. Since the last inspection we saw decisions made in people’s best interest had followed the correct procedure and accurately recorded.

People received a varied and healthy diet that offered choice and met their needs. Everyone we spoke with was complementary about the meals provided.

There was a range of social activities and events available for people to take part in, if they wished to.

The service had an open and positive culture that encouraged involvement of people using the service, their families and staff. The registered manager, supported by senior managers in the company, was visible and promoted teamwork.

People were encouraged to raise concerns or complaints and were asked for feedback about the service they received. Staff spoke positively about the registered manager and had a clear understanding of their roles and responsibilities.

Regular checks were in place to identify areas of service needed to improve and action had, or was being taken to address shortfalls found. Accidents and incidents were monitored and analysed so lessons could be learned.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘The Abbey’s’ on our website at www.cqc.org.uk’

At this inspection we found improvements had been made across the five domains and the breaches of Regulation found at the last inspection had been met. For instance, potential risks to people had been identified and better documented, and a more robust auditing system had been implemented, which meant shortfalls found had been identified and actioned in a timelier manner.

The Abbeys is a care home providing personal care and support for up to 80 people. Accommodation is provided in two separate buildings. The home is located on the outskirts of Rotherham and has good public transport links. At the time of our inspection there were 49 people using the service.

The service had a registered manager in post at the time of our inspection. 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.

Throughout our inspection we saw staff supporting people in an inclusive, kind, caring, responsive and friendly manner. They encouraged them to be as independent as possible, while taking into consideration their abilities and any risks associated with their care. The people we spoke with made positive comments about how staff delivered care and said they were happy with the way the home was managed.

There were systems in place to reduce the risk of abuse and to assess and monitor potential risks to individual people. People had been involved in need assessments prior to moving into the home, as well as in planning their care. Care plans outlined peoples’ needs, risks associated with their care, as well as their abilities and preferences.

Overall the requirements of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS) legislation were met. However, we found some care files did not include documentation to evidence that decisions had been made in the person’s best interest. For instance, where two people had bed rails fitted for their safety there was no evidence that a best interest meeting had taken place to decide if this was the best option to take. However, we found no evidence to indicate that people’s best interest was not being represented.

Medication administration was being safely managed and where people required medicine on an ‘as required’ basis protocols had been introduced to provide additional guidance for staff.

Recruitment processes were robust, which helped the employer make safer recruitment decisions when employing new staff. Staff had undertaken a range of training and support that aimed to meet people’s needs while developing staffs’ knowledge and skills.

The provider had suitable arrangements in place that ensured people received good nutrition and hydration. Care files identified any specific dietary needs people had, and staff were knowledgeable about each person’s individual preferences and needs.

We saw the complaints policy was available to people who used and visited the service. The people we spoke with told us they would feel comfortable speaking to any of the staff if they had any concerns. Complaints received had been recorded and investigated appropriately.

There were systems in place to enable people to share their opinion of the service provided. This included meetings, surveys and reviews.

The local authority had told us that when they visited the home in May 2017 they found areas that needed improving. The infection control nurse had also carried out an audit at the home in May 2017, with a follow up visit in August 2017, when they found vast improvement from their earlier audit. At this visit we saw further work had been carried out, or was planned to address a few areas still needing addressing.

The Abbeys is a care home providing personal care and support for up to 80 people. Accommodation is provided in two separate buildings. The home is located on the outskirts of Rotherham and has good public transport links. At the time of our inspection there were 59 people using the service.

The service had a registered manager in post at the time of our inspection. 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 service had a medication policy which outlined how medicines should be safely managed. However, this was not always followed. People who required medicine on an ‘as required’ basis did not always have a protocol in place.

We looked at care files belonging to people who used the service and found, in most cases, the risks associated with their care had been identified. However, some records did not include an assessment of risks and how they could be prevented.

We looked at three staff recruitment files and found the provider had a safe and effective system in place for employing new staff.

The provider had suitable arrangements in place that ensured people received good nutrition and hydration. However, we found people did not always receive the specific diet in line with their needs, putting them at risk.

The requirements of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS) legislation was not always met. Some care plans did not include documentation to evidence that decisions had been made in the person’s best interest.

Staff told us they received training appropriate to their job role. Staff told us that they attended training on a regular basis.

We observed staff interacting with people throughout the inspection. Staff engaged in a positive way which encouraged people to make decisions about how to spend their day. However, we saw some instances where this could have been done better.

Staff we spoke with explained how they maintained people’s privacy and dignity. We also saw that care plans documented people’s likes and dislikes.

People’s needs were assessed and care and support was provided on an individual basis. However, we saw one person’s plan did not reflect the support that was delivered to them.

An activity co-ordinator was employed at the home and delivered and organised activities.

The service dealt with complaints effectively. We saw evidence that the registered manager had acted appropriately to resolve concerns. People we spoke with told us that they could speak with the registered manager if they had concerns.

We saw several audits were completed on a regular basis with the intention of ensuring that a quality service was being provided to people who used the service. However, some of the issues we identified had not been identified as part of these audits and had therefore not been addressed.

There was evidence that people who used the service had a voice and were given the opportunity to complete a quality questionnaire. Relatives meetings had also been set up but were not well attended.

Our inspection identified two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of this report.

The Abbeys is care home which provides personal care for up to 80 people, including those living with dementia. Accommodation is provided in two separate buildings, the main home where the registered manager is based, The Abbeys, and the Abbeydale unit which is in the same grounds. It is located on the outskirts of Rotherham and has good public transport links. At the time of our inspection there were 48 people using the service.

The service had a registered manager in post at the time of our inspection. 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 in post approximately five months and was in the process of setting up systems and processes to assist in the management of the service.

Some people we spoke with felt staffing levels were low. We spoke with the registered manager who told us this would be kept under review. We observed care and in the main people’s needs were met.

People received their medicines safely and they were appropriately stored. We looked at records in relation to medicines and found some had not been completed correctly.

The provider had a robust recruitment policy and pre-employment checks were carried out prior to new employees commencing their role.

We looked at care plans and found they contained a section on risks relating to people’s care and support. These included risk assessments for chocking, malnutrition, dehydration, and moving and handling.

We saw records to show staff had completed training relevant to their roles. However some training was required and we saw a training plan which addressed this.

The provider was meeting the requirement of the Mental Capacity Act 2005. Where people lacked capacity, decisions were made in the person’s best interest.

People were offered a nutritious diet and choices were available. We saw snacks and drinks were offered throughout our inspection.

We saw people were referred to other professionals when required to meet their healthcare needs. People we spoke with and their relatives said this would be done without delay.

We observed care workers on the upstairs unit which provided support for people living with dementia. Staff were polite and friendly but on occasions did not show strategies for managing difficult situations.

Staff could explain to us how they would ensure people’s dignity was respected. However, we saw one person’s trousers were very creased. This showed a lack of dignity and respect for the person.

The home employed an activity co-ordinator who organised social events for people. A lot of people preferred to spend time in their bedrooms.

Care plans were in the process of being updated and the registered manager told us this was being addressed as a priority.

The home had a complaints procedure displayed in the entrance of the home. People felt they could raise concerns and felt confident that they would be addressed.

People we spoke with felt the management team were approachable. Most people knew the registered manager and were happy to talk with her regarding their care.

We saw several audits had been undertaken to ensure the quality of service provision. These included audits for care plans, medication, mealtimes, and catering. We also saw provider audits had been completed.

We saw evidence that people were involved and consulted about the service. We saw relatives had completed surveys to give feedback about their experience of the home.