Abbeywood House

Updated 22 December 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.

Inspection team

The inspection was carried out by 3 inspectors.

Service and service type

Abbeywood House 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.

Abbeywood House 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 a registered manager in post.

Notice of inspection

This inspection was unannounced. Inspection onsite activity was carried out on 12 and 19 October 2023.

What we did before the inspection

Before the inspection we reviewed the information we held about the service, including notifications we had received. Notifications are changes, events, or incidents the provider is legally required to tell us about within required timescales. We sought feedback from the local authority and 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 this information to plan the inspection and took this into account when we inspected the service and made the judgements in this report.

During the inspection

We spent time with and spoke with 9 people living at the service, 2 relatives, 7 members of staff, and the registered manager. 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. To help us assess and understand how people's care needs were being met we reviewed 7 people's care records. We also reviewed a number of records relating to the running of the service. These included staff recruitment and training records, medicine records and records associated with the provider's quality assurance systems.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at care plans, training data and quality assurance records and spoke with a representative from Torbay Council, and 8 relatives.

Updated 22 December 2023

About the service

Abbeywood House is registered to provide personal care and support for up to 33 older people some of whom may be living with a dementia or physical frailty. The home does not provide nursing care; people living there would receive nursing care through the local community health teams. At the time of the inspection there were 32 people living at the service.

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

People mostly told us they liked living at Abbeywood House, they were safe and happy. However, we received mixed feedback from relatives regarding people’s experiences.

We found the service was not always operating in accordance with the regulations and best practice guidance. Some systems were either not in place or had not been undertaken robustly to identify and monitor the quality of the service and drive improvements. This meant some systems operated by the provider had failed to identify concerns and shortfalls we found during this inspection and could not be relied upon as a source to measure quality and risk.

People were not always protected from the risk of avoidable harm. We found where some risks had been identified, enough action had not always been taken to mitigate those risks and keep people safe.

People were not always supported to have maximum choice and control of their lives and staff were not always supporting people in the least restrictive way possible. The service could not always demonstrate they were acting in people’s best interests.

People were at risk of receiving care that did not meet their needs and people’s needs were not always assessed prior to admission.

Staff had a good understanding about how people communicated and used this knowledge to support people to make day to day choices. However, we have made a recommendation in relation to accessible information.

Staff were recruited and employed in sufficient numbers and completed regular training. However, we have recommended the provider undertake a review of the effectiveness of their training programme.

Most medicines were given safely and correctly. However, we have made a recommendation about people’s medicines as some improvements were needed.

People knew how to make a complaint and felt confident they would be listened to if they needed to raise concerns.

The management team were committed to providing good quality care and were responsive to the feedback we gave 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 good (published 22 November 2018).

Why we inspected

This inspection was prompted by a review of the information we held about this service.

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.

The overall rating has changed from good to requires improvement. 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 Abbeywood House on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to safe care and treatment, need for consent, person centred care, safeguarding service users from abuse and improper treatment, notifications and good governance at this inspection. We have also made recommendations in relation to medicines, staff training and accessible information.

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.