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Archived: Abbey Lodge Care Home

Overall: Inadequate read more about inspection ratings

Cranmere Avenue, Tettenhall, Wolverhampton, West Midlands, WV6 8TW (01902) 745181

Provided and run by:
Abbey Lodge Care Limited

All Inspections

18 January 2022

During an inspection looking at part of the service

About 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.

23 June 2021

During an inspection looking at part of the service

About the service

Abbey Lodge Care Home is a residential care home that can provide personal care for up to 26 people. The service was supporting 14 people at the time of the inspection

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

People were supported safely by suitably trained staff who understood how to recognise and report any signs of abuse. Staff were trained to administer medicines safely.

There were enough staff to meet people’s needs and were able to support people effectively and safely. Peoples risks were assessed and planned for and had access to other professionals when needed.

People were protected from the risk of cross infection by staff who followed the latest government guidance around Covid-19.

Quality assurance processes were in place and audits had been carried out to identify areas of the service that required improvement.

Improvements to the environment had been made and these were ongoing.

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

Rating at last inspection (and update)

The last rating for this service was inadequate (published 21 January 2021) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

This service has been in Special Measures since 21 January 2021. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from inadequate to good. 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 Abbey Lodge Care home on our website at www.cqc.org.uk.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

7 October 2020

During an inspection looking at part of the service

About the service

Abbey Lodge Care Home is a residential care home that can provide personal care for up to 26 people. The service was supporting 21 people at the time of the inspection.

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

People had been placed at significant risk of harm. The provider had failed to ensure people were protected against the risks of cross infection in regard to COVID-19. The provider had failed to ensure adequate infection control practices and relevant actions required to mitigate potential risks were followed, which placed people at risk.

Medicines were not effectively managed. Some medicines including controlled drugs were not stored or administered safely. Records were not in place for topical medicines and ‘as required’ medicines did not have specific instructions available which could put people’s at risk.

People were at risk as a suitably qualified member of staff was not available at all times to administer medications.

People's care plans were not reviewed to ensure they contained accurate information about their needs to enable staff to deliver the care they required.

Staff had not received adequate training to do their jobs effectively to ensure people were supported safely. Staff were rushed and care they delivered was task focussed, leaving no time for one to one time or any activities.

Adequate quality assurance systems were not in place. Audits had not been carried out consistently or could not be located. This meant improvements to the service were not identified and acted upon.

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 7 June 2018).

Why we inspected

The inspection was prompted by a notification of a specific incident. Following which a person using the service sustained a serious injury. This incident is subject to a criminal investigation. As a result, this inspection did not examine the circumstances of the incident.

The information CQC received about the incident indicated concerns about the management of risk throughout the home.

You can see what action we have asked the provider to take at the end of this full report.

Enforcement

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 discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to safe care and treatment, staffing and governance.

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

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.

9 May 2018

During a routine inspection

This inspection took place on the 09 and 14 May 2018. The first day was an unannounced visit and the second day was announced to review records and speak with the registered manager and provider.

This was the first inspection of this service since registering with the Care Quality Commission on 19 February 2017.

Abbey Lodge Care Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Abbey Lodge is registered to provide accommodation for up to 26 people. At the time of inspection there were 21 people living at the home. Abbey Lodge is arranged over two floors, the second floor was for people who are more independent. Many of the people living at Abbey Lodge are living with dementia.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.’

People were safe because there were sufficient levels of staff to meet people’s needs. Risks were identified, assessed and managed effectively. The provider had systems in place to minimise the risk of abuse and staff had a good knowledge and understanding of what abuse is and where to report concerns. The provider carried out appropriate pre-employment checks before staff started work.

Medicines were managed safely and staff had a good knowledge of when people required their ‘as required’ medication. Accidents and incidents were recorded and there were measures in place to review these to reduce the risk of reoccurrence. People were protected from the risk of infection because the home was kept clean.

Staff had the relevant skills and knowledge to meet people’s care and support needs. People and their relatives were positive about the care provided and our observations confirmed that staff were kind and caring. Staff sought consent before providing care to people and principles of the Mental Capacity Act had been followed when people lacked capacity to make specific decisions regarding their care needs.

People were supported to maintain a healthy diet and drink sufficient amounts of fluids. People had access to relevant health professionals and referrals made were timely and appropriate.

People and relatives we spoke with gave mixed views in relation to activities. Some people felt that there were not enough activities that were specific to people’s individual interests.

People, relatives and staff said they were kept up to date with any changes that were taking place and felt the management team was approachable. Relatives told us they felt confident to raise concerns with the registered manager and we found that complaints were dealt with appropriately.

Systems were in place to monitor and drive improvement within the home. We saw the registered manager developed an action plan each year to sustain improvements and highlight areas for improvement.

Relatives and staff spoke positively about the improvements the registered manager had made and staff told us they felt well supported to carry out their roles and responsibilities.