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Abbey Court Nursing and Residential Home Inadequate

We are carrying out a review of quality at Abbey Court Nursing and Residential Home. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary

Overall summary & rating


Updated 18 March 2020

About the service

Abbey Court Nursing and Residential Home is a nursing home providing personal and nursing care for up to 40 people. There were 36 people living at the home at the time of our inspection. The service provides support to older people with a range of support needs including complex health conditions and dementia.

The service is a large adapted property. Accommodation is split across three floors and there are several communal living areas.

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

Risks associated with people’s care and support and the environment were not managed safely. This placed people at risk of harm. Opportunities to learn from incidents had been missed. Medicines were not always stored or managed safely. There were not always enough staff to meet people’s needs and ensure their safety.

Overall, safe recruitment practices were followed, and the home was clean and hygienic, some equipment and furnishings required cleaning to ensure effective infection prevention.

People were not supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice. People were at risk of dehydration and malnutrition due to poor monitoring and failure to follow nationally recognised guidance.

Overall, people were supported with their health needs and had access to healthcare services, although care plans did not always contained personalised health information. Overall, the home was adapted to meet people’s needs. People were supported by staff who had the training and support required to provide effective care.

People were not always provided with dignified support and staff did not always respect their right to privacy. Whilst people told us staff were often kind and caring, we saw this was not always so. We received variable feedback about people’s involvement in their care.

People were not always provided with individualised care that met their needs and reflected their preferences. Staff did not consistently have a good understanding of people’s needs. There was limited evidence that people and their families had been given the opportunity to discuss their end of life wishes. People were provided with opportunities for activity and were supported to stay in touch with people who were important to them. People and their families felt comfortable raising any complaints or concerns.

Abbey Court was not well led. The registered manager did not have adequate time to oversee the running of the home. The provider did not operate effective governance systems to ensure the quality, safety or improvement of people’s care when needed. There had been a failure to identify and address issues with the health, safety and quality of care provided. Audits were not always effective, and the provider did not have sufficient oversight of the running of the home. There were limited opportunities for people and staff to get involved driving improvements. The management team worked in partnership with health and social care professionals and had links with the community.

For more details, please see the full report which is on the CQC website at

Rating at last inspection

The last rating for this service was requires improvement (report published 27 September 2019).

Why we inspected

The inspection was prompted, in part, due to concerns received about unsafe moving and handling practice and neglect of people’s care needs. A decision was made for us to bring the scheduled inspection forward and examine those risks.

We have found evidence that the provider needs to make improvements. Please see the Safe, Effective, Caring, Responsive and Well Led sections of this report.


We have identified breaches in relation to risk management, the environment, safeguarding, staffing, consent, how people are treated and leaders

Inspection areas



Updated 18 March 2020

The service was not safe.

Details are in our safe findings below.


Requires improvement

Updated 18 March 2020

The service was always not effective.

Details are in our effective findings below.


Requires improvement

Updated 18 March 2020

The service was not always caring.

Details are in our caring findings below.


Requires improvement

Updated 18 March 2020

The service was not always responsive.

Details are in our responsive findings below.



Updated 18 March 2020

The service was not well-led.

Details are in our well-Led findings below.