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Archived: Abbey Court Nursing Home - West Kingsdown Inadequate

Inspection Summary

Overall summary & rating


Updated 23 May 2020

About the service

We inspected the service on 17 December 2019 and 19 December 2019.

Abbey Court Nursing Home – West Kingsdown is registered to provide accommodation, nursing and personal care for 22 older people and people who have physical adaptive needs. There were 10 people living in the service at the time of our inspection visit. Most people lived with dementia and had special communication needs.

The service was run by Abbey Health Care Limited. The company was operated by two directors one of whom was also the registered manager.

People's experience of using the service and what we found

People said they did not consistently receive care meeting their needs and expectations. A person said, “The best you can say is the staff do try hard but it’s just not organised right. It’s hit and miss if you get the help you need. I’m not happy here and I want to move.”

We found there were continuing, multiple and serious shortfalls significantly increasing the risk people would not receive safe care and treatment. Safeguarding incidents were not reported or investigated appropriately. The registered provider and staff did not recognise or respond to safeguarding incidents or follow established local procedures for reporting and investigating them.

People were not adequately protected from the risk of harm in the event of a fire due as staff did not know what they should do in the event of an emergency. Known risks to people in relation to skin integrity, how people were moved safely and choking risks were not managed well which placed people at an increased risk of harm. Poor medicines practice and recording was identified as well as a lack of robust oversight of what actions should be taken to reduce the risk of incidents and accidents re-occurring.

There was a lack of staff which impacted on the care people received and recruitment practices were poor with little or no action taken by the registered provider when concerns about staff conduct were raised. Staff did not have the appropriate knowledge, competency or skills they needed to consistently provide people with the right care. This should have been identified by the registered manager and provider.

There were continuing, multiple and serious failings in the systems and processes used to monitor the safety and quality of the service. Quality assurance systems were ineffective and had not identified the serious concerns we found. The registered provider did not fully understand the duty of candour and had not always been open and honest when things had gone wrong. Important incidents that required CQC to be notified were not completed meaning we could not be assured we could effectively monitor the service.

People had not been fully consulted about the development of the service and good team work was not promoted. These shortfalls had resulted in people not consistently receiving the high-quality care they needed and had the right to expect. There were defects in the accommodation. The provision and recording of care did not enable people to be fully supported to receive coordinated care when they moved between or used different services. The registered manager had not worked effectively with other agencies to develop the service. Suitable provision had not been made to comply with the duty of candour.

Care was not always provided in ways promoting people’s dignity and respecting their right to privacy. Staff did not always consider or uphold peoples dignity. The culture in the service was one of being ‘done to’ rather than people having genuine choice and freedom to live as individuals.

People were not always supported to safely eat and drink enough to have a balanced diet and food choices were not always available to people. People were not supported to have maximum choice and control of their lives and they were not always supported in the least restrictive way possible and in their best interests.

People did not always receive responsive, person-centred

Inspection areas



Updated 23 May 2020

The service was not safe.

Details are in our safe findings below.



Updated 23 May 2020

The service was not effective.

Details are in our effective findings below.



Updated 23 May 2020

The service was not caring.

Details are in our caring findings below.



Updated 23 May 2020

The service was not responsive.

Details are in our responsive findings below.



Updated 23 May 2020

The service was not well-led.

Details are in our well-led findings below.