Abbeydale Nursing Home

Updated 9 March 2022

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

As part of CQC’s response to care homes with outbreaks of COVID-19, we are conducting reviews to ensure that the Infection Prevention and Control (IPC) practice is safe and that services are compliant with IPC measures. This was a targeted inspection looking at the IPC practices the provider has in place. We also asked the provider about any staffing pressures the service was experiencing and whether this was having an impact on the service.

This inspection took place on 22 February 2022 and was announced. We gave the service two hours’ notice of the inspection.

Updated 9 March 2022

About the service

Abbeydale Nursing Home is a residential care home providing nursing and personal care to 34 people at the time of the inspection. The service is registered to support up to 36 people in one adapted building. The home is located over two levels.

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

Records to document the completion of planned care were not always updated to reflect the care being given to people. However, we found staff were aware of the care needs of people and told us these had taken place even when they were not recorded fully.

Audits and checks were completed by the registered manager; however, these were not always effective at identifying concerns. There was a lack of robust oversight with aspects of the service. The registered manager implemented some new checks before the end of the inspection to improve oversight of some areas.

Risks to people were assessed and appropriate plans were in place to keep people safe. However, whilst people and relatives were involved in decisions where appropriate, healthcare professionals had not always been consulted to ensure decisions were safe for the person.

Accidents and incidents were recorded, and actions were in place to ensure people were safe. However, there were no systems in place to effectively analyse incidents to ensure learning could be implemented to prevent reoccurrence.

There were enough staff to meet people's needs. People told us they felt safe living at Abbeydale and liked living there.

Staff understood their role and had confidence in the manager. Staff told us they worked well together as a team, and there was good morale amongst them.

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 4 June 2019).

The service remains rated requires improvement. This service has been rated requires improvement for the last eight consecutive inspections.

Why we inspected

We carried out an announced focussed inspection of this service on 11 September 2020. We gave the service 30 minutes notice so we could make appropriate plans regarding covid-19. At the last inspection recommendations were made about safe recruitment processes and good governance.

We undertook this focused inspection to check they had made improvements to the recruitment process and governance of the service. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

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 coronavirus and other infection outbreaks effectively.

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 remained the same. 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 Abbeydale Nursing Home on our website at www.cqc.org.uk.

Enforcement

We have identified breaches in relation to good governance.

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 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 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.