CQC inspected this service on the 21, 24 and 25 July 2017. The first day of the inspection was unannounced which meant the provider was not expecting CQC on the date of the inspection.
The five questions we ask about services and what we found.
Is the service safe? Inadequate
The service was not safe.
There were not enough suitably trained staff to meet the needs of people living in the home. The top floor was a particular concern and needs further review even after an immediate increase to staff numbers. The Home’s plans in the event of an emergency evacuation were not consistent; staff did not have a clear message on how to safely support people in the event of an emergency.
Risk assessments for both the safety of the environment and the safety of people living in the home were not adequate.
The safe management of people’s medicines required more thought. Record keeping was inconsistent and plans to support people with their medicines were incomplete. People were not administered medicines safely and in line with prescriptions and protocols.
Is the service effective? Requires Improvement
The service was not always effective. Systems and records used to support people with the risks associated with malnutrition and dehydration, were not effective.
We found further work was required to ensure people had given suitable and required consent. These included people consented to their own care and treatment when they had the capacity to do so and when not, other suitable consent was acquired under the guidance of the Mental Capacity Act 2005 The service had begun to develop procedures of assessment and decision making under the Mental Capacity Act to support those people in their best interest.
Training and support provided to staff had improved over the previous months and staff were beginning to feel better supported.
The newly appointed trainer was a positive asset for the team’s development.
Is the service responsive? Requires Improvement
The service was not always responsive. The home had developed activities which were held in the home and external outings were planned.
The provider had developed a network of activities with other similar providers.
There was a shortage of meaningful activity and occupation for those living with dementia and this required further thought We found people’s care records were difficult to follow and information was not all held with the person’s file.
The quality of these records was inconsistent and we have made a recommendation for this information to be reviewed to ensure it holds the current picture for everyone living in the home. The home’s complaints policy was past its review date.
Complaints had not been handled in line with the policy or available procedure
Is the service well-led? Requires Improvement
The service was not always well led The new senior leadership team had introduced quality visits and a home improvement plan. This enabled a high level review of the service. However, the monthly and quarterly monitoring that should underpin this was not fully developed and had been 8 Abbey Wood Lodge Care Home Inspection report 22 February 2018 inconsistently completed.
The home was shifting its culture and staff and people in the home were more confident there would be improvements in service delivery. Risk assessments were basic and needed to more clearly identify the risk and how it would be managed.
Systems of quality monitoring were required to monitor the management of the identified risks. Policy and procedures were out of date and had not been updated for some time. New policies and procedures were yet to be embedded in the home.
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