Abbeywell Court

Updated 21 June 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection, we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by 2 inspectors. An Expert by Experience was used to telephone relatives. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Abbeywell Court is a ‘care home'. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Abbeywell Court is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 2 people who used the service and 12 relatives about their experience of the care provided. We spoke with 12 members of staff including the registered manager, area manager, senior care workers, nurses, care assistants, domestic staff, and the activities coordinator. We received feedback from 1 visiting professional.

We reviewed a range of records. This included 4 people's care records and multiple people's medication and care monitoring records. We looked at 3 staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including audits and policies and procedures were reviewed. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

Updated 21 June 2023

About the service

Abbeywell Court is a care home providing personal and nursing care to up to 45 people. The service provides support to older people, including people living with dementia, people with mental health concerns and younger adults. At the time of our inspection there were 38 people using the service. Care was provided in one adapted building across two floors. There were communal rooms available on each floor and an enclosed garden for people to enjoy.

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

During the last inspection, quality assurance processes were identified as requiring improvement. During this inspection we found improvements were still required to ensure risks were effectively monitored and care plans were kept in line with people’s changing needs.

Risks to people were not always managed or monitored safely. There were gaps in people’s repositioning charts and some medicines were not always effectively monitored or stored safely.

Staff received a detailed induction and on-going training. However, staff did not receive epilepsy training despite people with a diagnosis of epilepsy living in the home.

People were not always treated with dignity and respect. There was an occasion where staff did not respond to a person displaying distressed behaviour and on another occasion a person was not supported in a dignified way during lunch.

The provider acted quickly to the concerns identified. All care documentation was updated or amended accordingly. New systems were implemented to improve quality processes and medicine monitoring. The concerns regarding dignity and respect were addressed with the staff team and all staff were put on an epilepsy awareness course.

Staff were recruited safely. The provider used a dependency tool to ensure there were enough staff on duty to meet people's needs.

People told us they felt safe living in the home. Staff understood what was meant by abuse and told us how they would report their concerns.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People’s preferences and cultural beliefs were respected. People and relatives praised the meaningful activities which took place in the home.

Relatives and staff had confidence in the manager's ability to lead the service. A visiting professional confirmed how the provider worked in partnership to achieve positive outcomes for people.

People, relatives and staff felt involved in the home and felt able to offer suggestions and raise concerns openly.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was requires improvement (published 01 July 2022). The service remains rated requires improvement. This service has been rated requires improvement for the last 2 consecutive inspections.

Why we inspected

We received concerns in relation to staff training, the management of medicines care and risk monitoring. As a result, we undertook a focused inspection to review the key questions of Safe and Well-led only. We inspected and found there was a concern relating to the dignified care and treatment of people, so we widened the scope of the inspection which included the key question of Caring.

The provider acted quickly on all concerns and put in systems and processes to address each area. We will review these in our next inspection.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has remained Requires Improvement. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Abbeywell Court on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to risk monitoring and recording, safe managing of medicines and governance systems at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.