Abbey Care Complex

Updated 2 December 2022

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 an inspector and an 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

Abbey Care Complex 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 Care Complex 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. There was a manager who commenced working at the service on the 10 October 2022. The area manager told us that it was the intention of the provider that the manager would apply to be registered with the Care Quality Commission in the near future.

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 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

During the inspection we spoke with 4 people who used the service and 4 relatives. We spoke with 14 staff. This included the manager, area manager, deputy manager, chef, dementia lead, two administrators, two registered nurses, three health care assistants, one senior care assistant and the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We observed how staff interacted with people. We looked at 15 care records and multiple medicines records for people, and staff recruitment files. We examined records related to the running of the service, including policies and procedures.

Updated 2 December 2022

About the service

Abbey Care Complex is a residential care home providing personal and nursing care to up to 50 people. The service provides support to predominantly older people, many of whom have nursing care needs or are living with dementia. At the time of our inspection, there were 44 people using the service. The home is purpose built, over four floors. The basement floor houses the kitchen and offices, while people live on the upper three floors.

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

Risk assessments were not always sufficiently detailed and sometimes lacked important information about how to mitigate risks people faced. There were no established schedules in place for ensuring communal areas of the home were cleaned. Quality assurance and monitoring systems were not always effective. People and relatives told us the quality of the food could be improved and we have made a recommendation about this.

There were enough staff to support people and robust staff recruitment practices were followed. Medicines were managed in a way that was safe. Systems were in place to protect people from the risk of abuse. Steps had been taken to ensure the physical environment was safe. Lessons were learnt when things went wrong.

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.

The provider was aware of their regulatory requirements and worked with other agencies to develop best practice and share knowledge. Staff spoke positively about the management of the service and the working atmosphere. Managers and staff were clear about their roles.

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 Good (published 29 September 2021).

Why we inspected

We received concerns in relation to people’s nursing needs, the management of the service and food provided. As a result, we undertook a focused inspection to review the key questions of safe and well-led, and the nutrition section of effective.

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.

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 Good to Requires improvement based on the findings of this inspection.

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

Enforcement and Recommendations

We have identified breaches in relation to the way people’s risks were assessed and infection control practice at the service, in addition to the quality assurance and monitoring processes. We have also made a recommendation about reviewing the food that is served.

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.