Archived: Abbey Grange Residential Home

Updated 5 August 2017

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, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

We made an unannounced inspection on 22 June 2017. The inspection team consisted of two Inspectors and one 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. They had knowledge and experience of care for older people.

We looked at the information we held about the service and the provider. We looked at statutory notifications that the provider had sent us. Statutory notifications are reports that the provider is required to send us by law about important incidents that have happened at the service. This information helped us to focus the inspection.

We asked the local authority if they had any information to share with us about the care provided by the service. Due to ongoing concerns regarding the care people receive, there was a local authority action plan in place with the provider. This set what concerns the local authority had, and what action they expected the provider to take.

We used the Short Observational Framework for Inspection (SOFI) because some people were unable to communicate with us verbally so we used different ways to communicate with people. SOFI is a specific way of observing care to help us understand the experience of people living at the home.

We spoke with eight people who lived at the home, and three relatives . We spoke with the manager, the deputy manager, the provider, and three members of staff. We also spoke with five health professionals. which included two district nurses, a social worker, a mental health professional, and a best interest assessor. We looked at one capacity assessment and Deprivation of Liberty Safeguard; a weight loss care plan; two skin integrity risk assessments; and one mobility risk assessment. We also looked at the provider's risk assessment for the premises, and two quality assurance audits.

Updated 5 August 2017

We carried out an unannounced inspection of this service on 9 and 16 February 2017. Breaches of legal requirements were found, and we issued a Warning Notice, which the provider was told they had to comply with by 22 June 2017. After the inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breaches.

We undertook this inspection to check that they had followed their plan and to confirm whether they now met legal requirements.

This inspection took place on 22 June 2017 and was unannounced.

At this inspection, we found the registered provider was still in breach of two of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 that we identified during the last inspection. These shortfalls in the service are described throughout all sections of this report.

Abbey Grange Residential Home provides accommodation and personal care for up to 29 people, some of whom are living with dementia. At the time of our inspection, there were 20 people living at the home.

There was a registered manager in post, who was also the registered provider. 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 and associated regulations about how the service is run.

People were exposed to harm, both in terms of their physical environment as well as the care they received. Action had not been taken when a significant safety issue had been identified, which resulted in the local authority and Care Quality Commission having to intervene to ensure people's immediate safety. The provider failed to take action to address a gas leak for two weeks until we inspected the service. At this point the provider contacted the emergency gas service and people were evacuated from the home for their safety whilst the matter was dealt with.

People's risk assessments were not followed, which resulted in unsafe care and treatment. People's skin health was compromised due to the fact their specialist equipment had not been used.

The provider was carrying out building works, which resulted in a hazardous living environment. Although the provider had risk assessed the situation, they did not follow their own risk assessment to ensure people's safety.

Staffing levels were not sufficient to keep people safe, with the local authority having to request the provider arrange for additional staff to be on duty.

The provider had not taken action where risks had been identified by staff and brought to their attention. The provider had not identified the concerns we highlighted during the course of our inspection.

People felt lonely, bored and isolated. They were unable to enjoy their individual hobbies and interests.Professional and medical guidance was not followed, which meant people's health needs were not always met.

The principles of the Mental Capacity Act were not followed, resulting in inappropriate applications to deprive people of their liberty.

The provider's website contained a link to an outdated CQC inspection report and rating, which was misleading and did not demonstrate transparency.

People and their relatives were positive about the approach and attitude of staff. People's independence was promoted as much as possible. Staff training had improved, which had resulted in some positive improvements in their daily practice.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’.

Services in special measures will be kept under review; if we have not taken immediate action to propose to cancel the provider’s registration of the service, it will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their 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.

Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.