Abafields Residential Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant the management and leadership were inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to good governance.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always demonstrate a clear shared vision, strategy and culture which was based on inclusion, and engagement. They did not demonstrate a culture of continuous improvement for the service.

The new manager was aware of any risks or barriers to achieving strategic goals and had produced a detailed action plan to identify the required actions needed to rectify any deficits; they ensured staff now received mandatory and service specific training, in addition to staff supervision, appraisals and staff meetings. However, staff reported supervision sessions had not always been done. A staff member said, “I do have supervisions, but not for a while.” A second staff member told us, “My next supervision is due in September; the previous ones weren’t as often.”

The provider had a clear ‘statement of purpose’ and vision and strategy for the service which leaders were aware of; this document provided a range of useful information for people, including details of different staff roles, a description of the accommodation provided, information of the admission process, participation in care home life, personal care and personal preferences. The manager told us, “Our aim at Abafields is to provide every person with a comfortable and safe environment within a homely atmosphere, ensuring person-centred care is delivered and the quality of service users experiences are high.”

We saw staff demonstrated these values when we observed 2 staff assisting a person to transfer to a comfortable chair, using a hoist. There was a very good level of communication between staff and the person throughout the manoeuvre, with staff explaining to the person what was happening and what they needed to do themselves to assist in the safe and comfortable transfer.

Staff were empowered to be involved in care plan reviews and social worker meetings and to be a ‘keyworker’ for several people. Daily staff handovers between shifts, daily manager walkabouts and daily staff ‘flash’ meetings were used to ensure all staff were knowledgeable about the care needs of people they were supporting.

The manager now operated an ‘open door’ policy to assist staff in feeling comfortable in holding discussions, seeking advice, sharing their knowledge and asking questions. People knew who the manager was but were uncertain regarding the changes within management as the homeowner was on holiday and the previous registered manager had unexpectedly left the home. A staff member said, “Changes of management have led to a lot of uncertainty. It has got better since [new manager name] has started.” A second staff member told us, “The managers door is now open a lot more than it used to be which is better. [New manager name] is out and about a lot more helping us which makes us feel better.”

At the time of this inspection, there was no registered manager in post. The registered manager had left the home in June 2025, and a new manager was in the process of registering with CQC. The new manager was suitably experienced and qualified and had worked previously in the social care sector, including 19 years as a registered manager, so had the skills and competence to carry out their role. In the absence of a registered manager however, there had been a lack of oversight from the provider and there were no documented audits completed to demonstrate they were monitoring the quality of service effectively.

The new manager was knowledgeable about issues and priorities for the service and had access to appropriate support; they took full responsibility within their role and challenged poor performance when necessary. For example, notes of a staff ‘flash’ meeting on 19 June 2025, identified malodour concerns in the morning and clinical waste bags being dumped on the ground; there was an action for night staff to read their job description and sign to acknowledge they had read and understood it.

The manager emphasised the importance of every single staff role in the home due to their interdependency; this helped to ensure staff appreciated all their colleagues and everyone worked as a team. A staff member told us, “I enjoy the job and it’s a good place to work. All staff get on well and the culture is good.” A second staff member said, “The management is good, and I feel supported; they look after staff welfare.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff felt able to raise concerns and that they would be listened to. There were mechanisms in place for staff to speak up and a culture in place to encourage them to do so. Staff felt they could approach the management team whenever they wished and were positively responding to the support available. A staff member told us, “We are looked after here and can raise concerns if we have them.” A second staff member said, “The previous registered manager and deputy manager didn’t help with care and locked themselves away and refused to help with care; [new manager name] will help though.”

The manager had taken up the role of ‘freedom to speak up champion’; they had held informal discussions with staff and in staff supervisions. They shared experiences and examples from previous events with staff and as a result staff were feeling more empowered and confident in their roles. The provider was developing a ‘buddy up’ system to support staff. Relatives had commented they were pleased to be able to speak to management.

Details of how to make a complaint to the provider, local government social care ombudsman and CQC were available in the statement of purpose. A person told us, “I have complained once, and it was sorted within hours. It was about the phraseology that one of the male carers was using and I felt it was not appropriate, and he could have used more moderate language, and it needed to be toned down. But I spoke with the manager, and she had a word with him, and it was dealt with, he even came and apologised to me, and he has been great ever since. I couldn't wish for better treatment in here to be honest.”

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider employed a diverse workforce and promoted mutual respect within the team. Staff were asked to share their backgrounds so leaders could learn how to support them individually.

Staff were trained in equality and diversity. Information could be provided in alternative languages if required. The provider acknowledged religious events and planned to hold cultural celebration days with people in the future to share the knowledge and give a different experience. The provider recognised and acknowledged any prayer times and now had a dedicated room to provide a suitable environment for any staff religious needs.

Staff supervisions and meetings were held which assisted staff to express concerns or confirm they were treated equally, although these records were not always readily available. At the time of this inspection, the provider was in the process developing staff surveys to empower them to express themselves; following this the provider planned to develop a ‘what you said’ and ‘what we did’ outcome, so staff knew they were being listened to.

The manager identified action plans would be implemented to address any findings or issues, which would also be discussed with all staff. The manager encouraged staff to give feedback and ideas so there was an inclusive culture for all staff.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

There was a historical lack of provider oversight of governance arrangements, especially in the absence of a registered manager and an overarching action plan had been developed to assist with this, moving forward. Governance arrangements had not identified the issues we found with fire safety and missing checks for fire checks, gaps in people’s care records and care plans, capacity assessments not always being completed for certain restrictions.

The manager acknowledged the home required better oversight and support when they commenced in their role; they recognised the previous leaders had not always ensured governance arrangements were being systematically followed. The manager told us they appreciated there were gaps and estimated it may take at least 6 months before the required arrangements would be fully embedded.

The manager was responsible for ensuring all relevant CQC notifications were submitted, and safeguarding issues were reported and acted upon. At the time of the inspection information was being shared with staff on management and leaders’ responsibilities to give a greater understanding to staff of the range of regulatory responsibilities of the home. The provider was in the process of setting up staff champion roles, to empower strengths in staff and support staff with any weaknesses.

The provider had a business continuity plan, which covered the relevant areas. Policies which were reviewed as part of this inspection were up to date. A detailed schedule of improvement works to the physical building was in place; some works had been completed, and others were awaiting a contractor start date.

Revised governance arrangements were now starting to be implemented under the new manager, including quality assurance audits, surveys and feedback. There were daily walkaround audits to cover the everyday aspects of delivering care.

Daily flash meetings were held to ensure all information was being shared with all staff. A secure instant messaging platform group had been set up for leaders to ensure senior staff were able to contact management at any time with any queries, or to pass any relevant information. There were shift handover forms for completion by day and night staff and handover information was also on the electronic care plan system for all staff to read.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The manager and staff worked in partnership with local organisations including the local authority and social workers, doctors, district nurses, continence services, hospital discharge teams, mental health services, and the admission avoidance team, to ensure people had access to the support they needed. A person told us, “I see the chiropodist when they come in and I am going to the optician this afternoon.”

At the time of the inspection the manager informed us they would be asking these services to complete a survey, and to feed back to the management team on how the home can support them in their role. The manager was committed in ensuring people’s needs were being met in all aspects.

Management had already had discussions with the adjoining community centre to arrange a community party in the home and invite the local community to join in. Management had already introduced themselves to visiting professionals and had discussed how to mutually support each other.

The manager was in the process of developing a person-centred activity programme and had implemented activity surveys for people to complete to assist with implementing relevant activities according to people’s wishes. A plan was in place to make contact with the local primary school to request a meeting to discuss developing intergenerational activities moving forward.

A meeting with the local church had been arranged to discuss the support they could give for people wishing to maintain their religious activities. Staff also planned to research local events and activity programmes to discuss with people. A person told us, “I am fortunate as I can get out a bit, so I go into town or to get my hair done via taxi, I like to get out and am hoping to get back to my own place soon.”

New, and more in-depth surveys had been developed for visiting professionals to complete. District Nurses had already provided 2 sessions of face-to-face training for staff in the past recent few weeks and were very complimentary of the staffs caring attitudes and readiness for expanding their skills and knowledge.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

Since the departure of the registered manager the new management team had begun to implement more robust audits and daily walkaround checks to ensure issues were addressed in a timely manner. Action plans were developed and shared with the provider and staff; these were prioritised and actioned in a timely manner.

All staff we spoke with confirmed leaders encouraged them to speak up with ideas for improvement and innovation and actively invested time to listen and engage. A senior member of staff had completed the Bolton Hospice palliative care certificate.

There was an ongoing improvement plan which had been in place for several months, which was reviewed each week against priorities and progression. Audit action plans were shared with the provider/director to track priorities and improvements made.