18 January 2022
During an inspection looking at part of the service
Abbey Lodge Care Home is a residential care home providing personal and nursing care to up to 26 people. The service provides support to older people, some of which were living with dementia. At the time of our inspection there were 15 people using the service.
People’s experience of using this service and what we found
People were not supported by trained staff who understood their needs. People did not have care plans and risk assessments in place which contained accurate and up to date information about their needs. People were not supported safely when they were eating and drinking. People did not receive safe support with their medicines. There were not always staff on shift to support people with their 'as required' medicines at night.
People were not supported by staff who understood how to recognise and report safeguarding concerns. The provider also failed to ensure potential safeguarding concerns were reported to the local authority for investigation and review. People were not supported by staff who understood how to support them safely in the event of an emergency.
People were not supported by staff who understood current COVID-19 guidance and were adhering to this. People were not supported by sufficient staff to meet their needs in a timely way. People did not always have access to external professionals when they needed these resulting in significant risk of harm.
People were not supported to know who the management team were and how they could raise concerns. Quality assurance tools were either not in place or effective at identifying the concerns we found at this inspection. The culture of the home did not enable open communication with people and their relatives when things went wrong to promote learning and drive improvements.
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 good (published 30 July 2021).
Why we inspected
The inspection was prompted in part due to concerns received about the quality of care, people’s safety and the leadership and oversight at the home. A decision was made for us to inspect and examine those risks. We have found evidence that the provider needs to make improvements. Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.
Enforcement and Recommendations
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed. We have identified breaches in relation to people’s safe care and treatment, staffing
Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.
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.
Special Measures
The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.
If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.
For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.