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Archived: Abbey Grange Residential Home Inadequate

Inspection Summary

Overall summary & rating


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 timef

Inspection areas



Updated 5 August 2017

The service is not safe.

People were exposed to harm and were living in an unsafe and hazardous environment. People's specialist equipment was not used, resulting in compromised skin health. Risk assessments were not followed, both in relation to people's care needs and the physical environment.


Requires improvement

Updated 5 August 2017

The service is not very effective.

Professional and medical guidance was not always followed, which meant people's needs were not met effectively. The principles of the Mental Capacity Act were not adhered to.

There was a choice and variety in the food and drinks provided. There was an increased focus on staff training and development.


Requires improvement

Updated 5 August 2017

The service is not very caring.

People's views were not routinely taken into account. People had been exposed to a harmful situation, which did not demonstrate a caring approach.

People's independence was promoted as much as possible. People and relatives were positive about staff and their approach.


Requires improvement

Updated 5 August 2017

The service is not very responsive.

People were not able to enjoy their individual hobbies and interests. Although staff did know about people's preferences, these were not always taken into account. Staff did not always respond promptly to people's needs.

There was a system in place for capturing complaints and feedback.



Updated 5 August 2017

The service is not well-led.

The provider had not acted on significant risks to people's health, safety and welfare. The provider did not have their own system in place for monitoring the quality of care people received, with audits only being carried out when requested by the local authority.

Although staff had approached the provider with concerns about people's safety, no action was taken.