Background to this inspection
Updated
20 May 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 included checking the provider was meeting COVID-19 vaccination requirements. 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 team consisted of four inspectors. Three inspectors completed visits to the home over the period of 18 and 21 January 2022 and one inspector supported the visits off site by making calls to relatives, staff and professionals that work with the service.
Service and service type
Abbey Lodge Care Home 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 service did not have a manager registered with the Care Quality Commission. This means the provider is legally responsible for how the service is run and for the quality and safety of the care provided.
Notice of inspection
These inspection visits were unannounced.
Inspection activity started on 18 January 2022 and ended on 21 January 2022. We visited the home on both of these dates.
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 all of this information to help plan our inspection. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make.
During the inspection
We spoke with eight people who used the service and two relatives about their experience of the care provided. We spoke with thirteen members of staff including the provider, deputy manager, HR manager, senior carers, care workers, domestic staff and a cook.
We reviewed a range of records. This included eight people’s care records and multiple medication records. We looked at three staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.
After the inspection
We continued to review the information sent to us by the provider. This included staff training records and staff rotas. We also spoke with multiple professionals that work with the service.
Updated
20 May 2022
About the service
Abbey Lodge Care Home is a residential care home providing personal and nursing care to up to 26 people. The service provides support to older people, some of which were living with dementia. At the time of our inspection there were 15 people using the service.
People’s experience of using this service and what we found
People were not supported by trained staff who understood their needs. People did not have care plans and risk assessments in place which contained accurate and up to date information about their needs. People were not supported safely when they were eating and drinking. People did not receive safe support with their medicines. There were not always staff on shift to support people with their 'as required' medicines at night.
People were not supported by staff who understood how to recognise and report safeguarding concerns. The provider also failed to ensure potential safeguarding concerns were reported to the local authority for investigation and review. People were not supported by staff who understood how to support them safely in the event of an emergency.
People were not supported by staff who understood current COVID-19 guidance and were adhering to this. People were not supported by sufficient staff to meet their needs in a timely way. People did not always have access to external professionals when they needed these resulting in significant risk of harm.
People were not supported to know who the management team were and how they could raise concerns. Quality assurance tools were either not in place or effective at identifying the concerns we found at this inspection. The culture of the home did not enable open communication with people and their relatives when things went wrong to promote learning and drive improvements.
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 30 July 2021).
Why we inspected
The inspection was prompted in part due to concerns received about the quality of care, people’s safety and the leadership and oversight at the home. A decision was made for us to inspect and examine those risks. We have found evidence that the provider needs to make improvements. 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.
Enforcement and Recommendations
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed. We have identified breaches in relation to people’s safe care and treatment, staffing
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 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.
Special Measures
The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.
If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.
For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.