Abbey Rose

Updated 22 November 2018

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 16 October 2018 and was unannounced. The inspection continued on 17 October 2018 and was announced. The inspection was carried out by one inspector and an Expert by Experience on the first day. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service. The second day of the inspection was carried out by a single inspector.

Before the inspection we reviewed all the information we held about the service. This included notifications the home had sent us. A notification is the means by which providers tell us important information that affects the running of the service and the care people receive. We contacted the local authority quality assurance team and safeguarding team to obtain their views about the service.

Before the inspection, the provider completed a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make.

We spoke with seven people who used the service and met with four relatives. We received feedback from two health care professionals via the telephone.

We spoke with the care manager, provider and registered manager. We met with six staff and the head chef. We reviewed six people’s care files, five medicine administration records (MAR), policies, risk assessments, health and safety records, incident reporting, consent to care and treatment and quality audits. We looked at three staff files, the recruitment process, complaints, and training and supervision records.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experiences of people who could not talk with us. We also walked around the building and observed care practice and interactions between care staff and people.

Updated 22 November 2018

The inspection took place on 16 October 2018 and was unannounced. The inspection continued on 17 October 2018 and was announced.

The service is registered to provide accommodation and residential and nursing care for up to 24 older people. At the time of our inspection the service was providing residential care to 21 people.

Abbey Rose is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. People were supported in a large detached home which was spread over two floors. There was a large communal lounge and dining area on the ground floor. Access to the first floor was via lift or two staircases and there were accessible outside areas to the rear of the home and an enclosed garden.

At the last inspection in September 2017, we asked the provider to take action to make improvements in two areas. These were management of medicines and quality monitoring. These actions had been completed.

The home had 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.

The home was using overt surveillance within the home however, consent had not been sought and consultations had not been held with people and relatives for the use of it.

We have made a recommendation about the use of surveillance inside a care home

Improvements had been made and medicines were administered and managed safely by trained staff. Staff understood how to recognise signs of abuse and the actions needed if abuse was suspected. There were enough staff to provide safe care and recruitment checks had ensured they were suitable to work with vulnerable adults. People had person centred risk assessments which identified individual risks they faced and provided actions for staff to safely manage these. The service was responsive when things went wrong and reviewed practices in a timely manner.

People and families had been involved in assessments about their care needs and had their choices and wishes respected including access to healthcare when required. Their care was provided by staff who had received an induction and on-going training that enabled them to carry out their role effectively. People had their eating and drinking needs understood and met. Opportunities to work in partnership with other organisations took place to ensure positive outcomes for people using the service. Capacity assessments and best interest decisions were completed and up to date.

People, professionals and their families described the staff as caring, kind and friendly and the atmosphere of the home as homely. People were able to express their views about their care and felt in control of their day to day lives. People had their dignity, privacy and independence respected.

Improvements had been made regarding social engagement within the home. People told us they enjoyed activities within the home and an activities coordinator had been employed. People had their care needs met by staff who were knowledgeable about how they could communicate their needs, their life histories and the people important to them. A complaints process was in place and people felt they would be listened to and actions taken if they raised concerns. People’s end of life wishes were known including their individual spiritual and cultural wishes.

Improvements had been made in relation to quality monitoring and systems were in place to ensure people and relatives were involved in shaping the service. People, relatives and professionals told us that they had experienced improvements in the home since the last inspection. Leadership was visible and promoted teamwork. Staff spoke positively about the management and had a clear understanding of their roles and responsibilities. The service understood their legal responsibilities for reporting and sharing information with other services.