Abbeydale Nursing Home

We found the following examples of good practice.

There was an up to date infection prevention and control policy and all staff completed relevant training.

The service received a score of 92% at the most recent infection prevention and control audit.

There was a good supply of PPE which was available throughout the home. Staff followed guidance around the use of PPE.

Staff and people living at the home tested regularly for COVID-19 in line with guidance.

The registered manager made sure that visits from friends and relatives were facilitated safely.

Abbeydale Nursing Home is a residential care home providing nursing and personal care to 34 people at the time of the inspection. The service is registered to support up to 36 people in one adapted building. The home is located over two levels.

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

Records to document the completion of planned care were not always updated to reflect the care being given to people. However, we found staff were aware of the care needs of people and told us these had taken place even when they were not recorded fully.

Audits and checks were completed by the registered manager; however, these were not always effective at identifying concerns. There was a lack of robust oversight with aspects of the service. The registered manager implemented some new checks before the end of the inspection to improve oversight of some areas.

Risks to people were assessed and appropriate plans were in place to keep people safe. However, whilst people and relatives were involved in decisions where appropriate, healthcare professionals had not always been consulted to ensure decisions were safe for the person.

Accidents and incidents were recorded, and actions were in place to ensure people were safe. However, there were no systems in place to effectively analyse incidents to ensure learning could be implemented to prevent reoccurrence.

There were enough staff to meet people's needs. People told us they felt safe living at Abbeydale and liked living there.

Staff understood their role and had confidence in the manager. Staff told us they worked well together as a team, and there was good morale amongst them.

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 4 June 2019).

The service remains rated requires improvement. This service has been rated requires improvement for the last eight consecutive inspections.

Why we inspected

We carried out an announced focussed inspection of this service on 11 September 2020. We gave the service 30 minutes notice so we could make appropriate plans regarding covid-19. At the last inspection recommendations were made about safe recruitment processes and good governance.

We undertook this focused inspection to check they had made improvements to the recruitment process and governance of the service. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

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 coronavirus and other infection outbreaks effectively.

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 remained the same. 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 Abbeydale Nursing Home on our website at www.cqc.org.uk.

Enforcement

We have identified breaches in relation to good governance.

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 for the provider to understand what they will do to improve the standards of quality and safety. We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

People’s experience of using this service: At the last inspection we found people’s safety was compromised, and the safe domain was rated inadequate. All other domains were rated requires improvement. We asked the registered provider to complete an action plan to show what they would do and by when to improve the key questions Safe, Effective, Caring, Responsive and Well -Led. At this inspection we found there had been some improvements, and people’s safety was no longer being compromised.

The registered provider had completed significant refurbishment works since our last inspection. This had improved the overall safety and cleanliness of the service. There were still further improvements to be made. The registered provider showed us planned refurbishment works to further improve the service.

The registered manager had implemented new safety checks since the last inspection. This had improved the overall safety for people living in the home.

The quality assurance processes had improved since the last inspection. However, they were not always effective. We made a recommendation about this.

At the last inspection, we found people were not always receiving responsive care. At this inspection we found there had been improvements to this and people were being supported in ways that met their needs.

Recruitment processes were not always safe. We made a recommendation about this.

The management of medicines was safe. We found concerns with two treatment rooms as they were dirty and untidy. These had been thoroughly cleaned before we returned for the second day.

Staffing levels during the inspection appeared adequate. Staff could respond to people’s support needs in a timely way.

People living in the home told us they felt safe. They felt there were enough staff to meet their needs. Safeguarding and whistleblowing policies and procedures were in place. Staff completed safeguarding training and knew how to report any concerns they had. We saw that any safeguarding referrals were submitted to the local authority and CQC accordingly.

The registered provider had a complaints policy in place. People and relatives were familiar with the complaints process and told us they would feel confident approaching the registered manager and staff if they had any concerns.

Care plans were detailed and person-centred. They ensured people were able to receive care in line with their preferences.

Staff were supported with training, learning and development opportunities. Staff also received regular supervisions and told us they were supported on daily basis.

Risk assessments were detailed and ensured people were protected from avoidable harm.

People told us they had enough to eat and drink.

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

Rating at last inspection: Requires Improvement (Report published 6th December 2018)

Why we inspected: This was a planned inspection based on the rating at the last inspection.

Abbeydale Nursing Home is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

Abbeydale provides nursing and personal care for up to 36 people, many with a diagnosis of dementia. The home is located in Kirkdale, north of Liverpool City Centre. Accommodation is located over three floors with access to all areas of the home by a passenger lift. At the time of our inspection there were 25 people living at Abbeydale.

A registered manager was in post. A registered manager is a person who has registered with the CQC 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 previous comprehensive inspection took place in February 2018. The home was awarded an overall rating of ‘Requires Improvement’. We found breaches of regulations in relation to ‘Safe Care and Treatment’, ‘Good Governance’, ‘Staffing’ and ‘Dignity and Respect’. We asked the registered provider to take action to make improvements in relation to the concerns we identified. An action plan was submitted by the registered provider.

A focused inspection took place in July 2018. We received information of concern relating to the management of skin vulnerability and wound care. We looked at clinical support measures which were in place to support people with vulnerable skin. The focused inspection only concentrated on two of the five key questions we inspect against: effective and well-led. We found that the breaches of regulation in relation to staffing and good governance were met.

During this comprehensive inspection, we concentrated on all five key questions; is the service safe, effective, caring, responsive and well-led? Whilst some improvements had been made since the previous comprehensive inspection; concerns were still identified in relation to the quality and safety of care people received.

You can see what action we have taken to keep people safe at the back of the report.

We identified a continued breach of regulation in relation to ‘Safe Care and Treatment’ and a breach of regulation in relation to ‘Good Governance’. We found that not all actions from the action plan that had been submitted by the registered provider had been completed. We are taking a number of appropriate actions to protect the people who are living at the home.

During this inspection, we identified continued environmental concerns, ineffective health and safety checks and poor-quality assurance measures. People continued to receive inadequate care and their safety was being compromised.

We checked to see what quality assurance measures were in place to regularly monitor and assess the provision of care people received. We found that systems and processes were in place; however, these were not always effective. We found that health and safety audits and checks were not effectively identifying the risks we saw during the inspection and continued breaches of regulation meant that people were not receiving safe, effective, compassionate, high-quality care.

At the previous comprehensive inspection, we identified a breach of regulation in relation to 'dignity and respect'. Staff were unable to provide the level of dignified and respectful care they required due to inadequate staffing levels. During this comprehensive inspection, we identified that the level of care people received needed to be improved.

We checked to see if the registered provider was complying with the principles of the Mental Capacity Act, 2005. Mental capacity assessments were completed routinely carried and the necessary and ‘Deprivation of Liberty Safeguards’ (DoLS) were submitted to the local authority. However, we identified that ‘Best Interest’ decisions were not always conducted with family members or representatives.

We recommend that the registered provider reviews DoLS and 'Best Interest' processes.

Staffing levels were appropriately managed; staff were effectively deployed across the three floors to ensure people received a safe level of care.

Recruitment was safely managed. The appropriate recruitment checks were conducted; personnel files contained application forms complete with employment and education history, appropriate references and the necessary ‘Disclosure and Barring Service’ (DBS) checks.

Staff were supported with training, learning and development opportunities. Staff also received regular supervisions and told us they were supported on daily basis.

People told us they felt safe living in at Abbeydale. Safeguarding and whistleblowing policies and procedures were in place. Staff completed safeguarding training and knew how to report any concerns they had. We saw that any safeguarding referrals were submitted to the local authority and CQC accordingly.

We saw that accidents and incidents were recorded; although it was not always clear how trends were analysed or established. There was an accident/incident reporting procedure in place and staff understood the importance of recording and reporting such events that occurred.

Medication processes were safe. People were supported with their medication by trained staff, staff received the appropriate medication administration training and there was an up to date medication administration policy in place.

People received support by external healthcare professionals. Care plans and risk assessment contained guidance and advice for staff to follow.

We checked the quality and standard of food people received. People told us they were happy with the variety and choice of meal options and people were encouraged to share their likes, dislikes and preferences.

People were encouraged to engage in a range of different activities. We received positive feedback about the activities that were arranged; people and relatives felt that the variety of different activities had improved.

The registered provider had a complaints policy in place. People and relatives were familiar with the complaints process and told us they would feel confident approaching the registered manager and staff if they had any concerns.

Systems were in place to gather feedback from the people living at Abbeydale. People and relatives had the opportunity to share their thoughts and suggestions in relation to the quality and safety of care provided.

The registered provider had a range of policies and procedures in place. Policies were accessible to the staff team and contained relevant and up to date information.

The registered manager was aware of their regulatory responsibilities. They were notifying CQC of events and incidents that occurred in the home; this enabled us to monitor and assess the quality and safety of care people received.

This unannounced focused inspection took place on 5 and 12 July 2017.

Abbeydale Nursing Home is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. Care Quality Commission regulates both the premises and the care provided, and both were looked at during this inspection.

Abbeydale provides nursing and personal care for up to 36 people, many with a diagnosis of dementia. The home is located in Kirkdale, north of Liverpool City Centre. Accommodation is located over three floors with access to all areas of the home by a passenger lift. At the time of our inspection there were 29 people using the service.

During a previous inspection in February 2018 we rated the service ‘requires improvement’ and found the registered provider was in breach of regulations in relation to staffing levels, conflicting information within risk assessments and lack of effective quality monitoring systems. During this inspection we found some improvements had been made and the provider was no longer in breach of those regulations within the key questions we looked.

There was a registered manager in post. A registered manager is a person who has registered with the CQC 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’s nutritional needs were assessed and met to ensure they maintained a health balanced diet; care plans clearly identified people with specific dietary requirements and provided guidance for staff to manage this. Staff provided effective support to people during meal times where required and were observed to do so in a calm, unrushed manner.

Consent for care was obtained in accordance with the Mental Capacity Act 2005; staff showed a good awareness of the need to obtain consent when providing care and support.

Sufficient numbers of suitably trained staff had been deployed to meet the needs to people living in Abbeydale. Staff were supported through regular supervision and appraisals.

People were supported with access to other health and social care professionals such as GP, podiatrist, opticians and wound specialists.

The quality and safety of the service was regularly monitored with the use of effective audits and checks completed by the registered manager, provider and external consultant team. Where issues were identified, clear action plans were in place to address them.

The registered manager notified CQC of important incidents and events that occurred within the home.

Whilst improvements have been made since the previous inspection in February 2018, we have not revised the overall rating from ‘requires improvement’. To receive a rating of ‘good’ this requires evidence of consistent long term good practice.

A full comprehensive inspection will be carried out later this year to look at outstanding areas of concern.

At the last comprehensive inspection in May 2017, we rated the service ‘Requires Improvement’ and found the provider was in breach of regulations in relation to safe care and treatment, good governance and staffing. This was the fourth consecutive time the service had been rated ‘Requires Improvement’.

During this inspection we looked to see whether improvements had been made to ensure the provider was meeting the fundamental standards of care.

This service has been rated 'requires improvement' in well-led (and overall) for the past four inspections; lack of effective management, leadership and provider oversight have resulted in the inability to maintain a good standard of care for people using the service.

Abbeydale Nursing Home 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.

Abbeydale provides nursing and personal care for up to 36 people, many with a diagnosis of dementia. The home is located in Kirkdale, north of Liverpool City Centre. Accommodation is located over three floors with access to all areas of the home by a passenger lift. At the time of our inspection there were 34 people using the service.

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.

Whilst some improvements had been made since the previous inspection we still had concerns about the quality of service being provided to people living in Abbeydale.

We found the environment was not always safe; this was because sluice rooms containing equipment that could be harmful to people were left unlocked. Action was taken to rectify this during the inspection.

The environment was not always clean and well maintained; this was because on the first day of the inspection some areas of the home were found to be unclean and odorous. Whilst some areas of the home had been refurbished, the registered manger told us there were plans to continue with the refurbishments to cover all areas.

We found the provider remained in breach of Regulation 12 of the Health and Social Care Act 2008(Regulated Activities) Regulations 2014.

The service did not always deploy sufficient numbers of staff to meet the needs of people living in Abbeydale; this was because on the first day of the inspection, two regular staff members were off which resulted in lower than usual staffing levels and because staff were not always appropriately deployed to where support was required the most.

We found the provider remained in breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Assessments in place to manage and monitor people’s individual risks were not always accurate; this was because some care files contained assessments with conflicting information and recorded risk levels.

We saw that whilst systems and processes were in place to monitor the quality and safety of the service, these were not always effective.

Files containing information relating to the care and treatment of people using the service were not always stored securely.

We found the provider remained in breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People spoke positively about the care being provided by staff at Abbeydale. People and relatives told us that staff were kind and caring. However we observed that staff were not always kind and caring towards people. We also observed that staff did not always treat people with dignity and respect; this was because on the first day of the inspection poor staffing levels meant that staff were not always able to interact positively with people in the home.

We found the provider to be in breach of Regulation 10 of the Health Social Care Act 2008 (Regulated Activities) Regulations 2014.

People told us they felt safe living in Abbeydale.

We observed a member of staff administering medications and checked records, stock, storage arrangements and audits and found that medicines were managed and stored safely.

Staff were aware of different types of abuse and how to report safeguarding incidents. Those that were reported had been done so appropriately. They were also aware of the whistleblowing policy. Staff were able to explain how to keep residents safe from abuse.

Staff recruitment files were checked and found to reflect safe recruitment processes. Each file contained an application form with detailed employment history, photographic identification, references and evidence of Disclosure and Barring Service (DBS) checks.

We saw evidence of the recording and monitoring of incidents and accidents. The records that we saw detailed and showed evidence of review and analysis by the registered manager.

Principles of the Mental Capacity Act (MCA) 2005 legislation were being followed and Deprivation of Liberty Safeguard (DoLS) applications were completed correctly and in line with current legislation. Staff showed a basic knowledge and understanding of both MCA and DoLS.

Systems were in place to assess people’s capacity to make specific decisions. Best interest decisions were documented correctly and consent for care and treatment was gained in line with the principals of the MCA.

Staff induction met the requirements of the Care Certificate. Records showed that staff had received training in areas such as manual handling, dementia, infection control, safeguarding and first aid.

Although people were supported with nutritional needs, staff were not always observed to support people during meal times where required. People spoke positively about the meals provided at Abbeydale and the chef was aware of people's dietary needs and preferences.

Staff were supported in their role through regular supervisions and appraisals; staff told us they were able to discuss any concerns or training needs during supervision and felt these would be addressed.

People in Abbeydale were supported to maintain good health in conjunction with a range of community health care services. We saw from care files that people received support and advice from health (and other) care professionals such as GP, district nurse, dietician, community mental health and podiatrist.

Care plans provided staff with information on how to support people whilst promoting their independence.

People and their relatives were involved in the decisions regarding the care and support being provided. People had a choice as to how care was delivered.

We saw from care records that they were person centred and based on individual needs and requirements. The care files that we saw were reviewed and updated regularly and provided detailed guidance for staff to provide support on an individual basis.

The service supported people with Equality, Diversity and Human Rights (EDHR) needs/wishes.

The service had a complaints policy that provided details of how people could make a complaint. The complaints log contained details of the complaint being made and the action taken by the manager.

The service employed an activities coordinator four times a week who provided a wide range of activities for people in the home. We observed a notice board that contained information regarding activities for the week ahead.

The registered manager had notified the Care Quality Commission (CQC) of events and incidents that occurred in the home in accordance with our statutory notifications.

Systems were in place to gather feedback regarding the service, this included surveys from people using the service, relatives and professionals.

Staff told us the manager’s aim was to ensure that people using the service came first and to provide good quality care. However, this was not always seen during the inspection.

Abbeydale Nursing Home provides nursing and personal care for up to 36 people, many with a diagnosis of dementia. The home is located in Kirkdale, north of Liverpool City Centre. The home is located near to public transport links and other community facilities. During the inspection, there were 35 people living in the home.

At the last comprehensive inspection in April 2016, the provider was found to be in breach of regulations. The breaches were in relation to the management of medicines and auditing systems. We re-inspected the service in August 2016 to check that improvements had been made in these areas; however the provider was still in breach of regulations. We re-inspected the service in October 2016 and found that sufficient improvements had been made and the provider was no longer in breach of regulations. However, we did not change the rating at this inspection as consistent good practice needs to be demonstrated over a longer period of time. During this comprehensive inspection in May 2017, we checked to see that improvements had been sustained.

We looked at the systems in place for managing medicines within the home and found that they stored, administered and recorded safely. We checked the stock balance of nine medicines and they were all accurate. We found that improvements regarding the management of medicines had been sustained.

We found that the environment was not always maintained safely. For instance, a cupboard was unlocked that contained cleaning chemicals and there were trip hazards within the garden. We saw a number of fire doors wedged open during the inspection, including two bedrooms. Action was taken to rectify this during the inspection.

Risk assessments in place to monitor people’s health and safety, were not all appropriate, such as the assessment in place which supported a person’s bedroom door being wedged open.

The provider and registered manager completed audits to monitor the quality of the service. However, these were not always effective.

Improvements that had been made following previous inspections, had not all been sustained.

Files containing information relating to the care and treatment provided to people were not stored securely.

Systems were in place to assess people’s capacity to make specific decisions. We saw that best interest documents were not always fully completed, however care was provided appropriately in people’s best interest.

Staff induction did not meet the requirements of the Care Certificate. Staff told us and records showed that staff had undertaken training in a variety of areas, however that not all staff had completed required safeguarding training.

Feedback regarding staffing levels was mixed. The registered manager told us they had identified that at times during the day it could be very busy and were in the process of recruiting three carers. We made a recommendation regarding this.

People we spoke with told us they felt safe living in Abbeydale.

All staff we spoke with were knowledgeable regarding the safeguarding procedures and clearly explained how they raise any issues. We found that appropriate safeguarding referrals had been made.

We looked at how staff were recruited within the home and found that safe recruitment procedures were adhered to.

DoLS applications were made appropriately and care plans were in place to inform staff when an authorisation was in place.

Feedback we received regarding meals was mixed. People told us however, they always had enough to eat and there was always a choice available to them. The chef was aware of people’s dietary needs and preferences and we saw that this information was available within the kitchen.

People told us that staff were kind and caring and relatives we spoke with agreed. We observed people’s dignity and privacy being respected by staff during the inspection.

Care plans were in place that were detailed and person centred and all plans were reviewed regularly. They reflected people’s preferences and life histories which helped staff get to know people and provide appropriate support.

Care plans provided staff with information on how to support people whilst promoting their independence and people we spoke with confirmed their independence was encouraged.

People told us they had choice as to how they spent their days and the care that they received. We saw that people’s preferences regarding this were recorded in their care files.

People we spoke with told us the service supported them to meet their cultural and religious needs.

People we spoke with told us their family members could visit them at any time and we saw that people could visit their relatives in private should they wish to.

Most people we spoke with told us they were aware of their care plan or that their family members had been involved in it.

Relatives we spoke with told us they were kept informed of any changes to their loved one’s health and wellbeing. Staff were kept informed if people’s needs changed, through daily verbal and written handovers, use of the daily reports and by reading people’s care plans.

We observed staff interacting with people throughout the inspection and from conversations we heard it was clear that staff knew people well.

We saw a schedule displayed within the home and people told us they enjoyed the activities, as well as spending time in the garden during the summer and having BBQ’s.

Everybody we spoke with told us they were aware how to make a complaint should they need to. The registered manager maintained a complaints log and we saw that complaints were dealt with appropriately.

Systems were in place to gather feedback from people regarding the service, including surveys and regular meetings.

A registered manager was in post and feedback regarding the management of the service was positive.

There were policies and procedures in place to guide staff in their role and staff were encouraged to share their views regarding the service.

The registered manager had notified the Care Quality Commission (CQC) of events and incidents that occurred in the home in accordance with our statutory notifications.

Ratings from the last comprehensive inspection were on display within the home as required.

CQC are considering our regulatory response.

We then undertook a follow-up inspection on 8 August 2016 to check that the provider had met the legal requirements. The inspection just focussed on the breaches and the recommendation. Although some improvements had been made, the breaches of legal requirements continued. The recommendation in relation to consent had not been addressed so we made this a breach of the legal requirement.

We undertook a further follow-up inspection on 4 October 2016 to again check if the legal requirements had been met. You can read the report from our last comprehensive inspection by selecting the 'all reports' link for 'Abbeydale Nursing Home' on our website at www.cqc.org.uk.

Abbeydale Nursing Home provides nursing and personal care for up to 36 people, many of whom are living with dementia. The home is situated in Kirkdale, north of Liverpool city centre and is located near to public transport links and other community facilities.

There were 30 people living in the home at the time of our inspection.

A registered manager was in post. A registered manager is a person who has registered with the CQC 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.

As the overall rating for Abbeydale Nursing Home was ‘Inadequate’ at previous inspections the home was placed into ‘Special measures’ by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

Services placed in Special Measures will be inspected again within six months and this inspection was undertaken within that timeframe to establish if sufficient improvements had been made. Adequate improvements had been made therefore the home has been taken out of Special Measures.

The management of medicines had improved. Senior carers were now administering medicines to people living at the home who were receiving residential care. The nurses administered the medicines to people receiving nursing care. This meant people were now receiving their medicines in a timely way. A more structured approach had been put in place to ensure people received topical medicines (creams) as prescribed.

We noted that improvements had been made in relation to seeking consent from people who lacked capacity to make complex about their care. For example, consent had been sought in accordance with the Mental Capacity Act (2005) in relation to the use of bedrails.

An external nurse clinical lead had been appointed and they had made improvements to individual risk assessments and care plans. These were now more detailed and reflected people’s current needs.

A range of audits or checks to monitor the quality of care provided was in place and since our last inspection. These had been modified to ensure they covered areas we had identified concerns with. Where appropriate, action plans were developed following each audit. A refurbishment programme was in place and this was reviewed each month to ensure identified actions/jobs had been completed.

A process was established to manage and monitor accidents, including a process for analysing accidents on a monthly basis. The registered manager provided us with examples of changes made as a result of the analysis identifying emerging themes.

While sufficient improvements had been made since the inspection in August 2016, we have not revised the ratings above ‘Requires improvement’. To improve the rating to ‘Good’ would require a longer term track record of consistent good practice.

Following the comprehensive inspection, the provider wrote to us to say what they would do to meet the breaches. We undertook this focused inspection to check that the provider was now meeting the legal requirements. This report only covers our findings in relation to these breaches and the recommendation. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘Abbeydale Nursing Home’ on our website at www.cqc.org.uk.

Abbeydale Nursing Home provides nursing and personal care for up to 36 people, many of whom are living with dementia. The home is situated in Kirkdale, north of Liverpool city centre and is located near to public transport links and other community facilities.

There were 25 people living in the home at the time of our inspection.

A registered manager was in post. A registered manager is a person who has registered with the CQC 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.

Although some improvements had been made to medicines management since the last inspection we found that the management of medicines was still not safe. Nurses were not always giving prescribed medicines at the correct time with regard to food. For example, a person was given their prescribed antibiotic with their meals which was not in accordance with the manufacture’s guidance that stated it must be given before food. Arrangements were not in place to order prescribed medication in a timely manner.

Records were not always made at the time medicines were given; this is not good practice because it relies upon people remembering to accurately fill in the records at a later time, which leads to inaccuracies. There was either no information or insufficient information to guide staff when administering medicines that were prescribed to be given ‘when required’ or as a ‘variable dose’.

There was no recorded information for nurses to refer to regarding people’s safe range for their blood sugars to ensure they were given their insulin safely. There were no care plans in place regarding what to do in the event of a diabetic emergency.

Audits or checks to monitor the quality of care provided were in place but were not effective as they had not picked up on issues we identified with medicines and care records.

There was no information recorded to indicate how people who used bedrails had consented to use of this equipment. Bedrails can be considered a form of restrictive practice so if a person is unable to consent to their use then ensuring they are used in a person’s best interest is important. We did not see that mental capacity assessments and best interest discussions had been completed for the use of bedrails.

Abbeydale Nursing Home provides nursing and personal care for up to 36 people, many with a diagnosis of dementia. The home is situated in Kirkdale, north of Liverpool city centre and is located near to public transport links and other community facilities.

There were 19 people living in the home at the time of our inspection.

Following the inspection in May 2015, the home was rated ‘inadequate’ overall. This meant the home was placed into ‘Special Measures’ by the Care Quality Commission (CQC). The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve.

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

Services placed in Special Measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration. A further inspection was undertaken on 5 and 6 November 2016 and the home was again rated as ‘inadequate’ overall so remained in ‘Special Measures’.

A registered manager was in post. A registered manager is a person who has registered with the CQC 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.

Although some improvements had been made to medicines management since the last inspection we found that the management of medicines was still not robust. There were numerous errors in relation to the administration, storage and monitoring of medicines. The home’s medicine’s audit had not identified the discrepancies we found.

Recruitment processes had improved and were effective in ensuring that new staff were suitable to work at the home. Support for staff had also improved. Staff told us they were receiving supervision on a regular basis and had received an annual appraisal of their performance. Records confirmed this. Records also confirmed that staff training was up-to-date.

Staffing levels had improved since the last inspection. People living at the home told us there were enough staff on duty at all times. Equally, visiting families and staff said there were sufficient numbers of staff on duty at all times to ensure people’s safety and to facilitate recreational activities. From our observations, we concluded there were enough staff to meet people’s needs.

The service was working within the principles of the Mental Capacity Act (2005). Restrictions that were in place to maintain people’s safety was done so lawfully and in accordance with the Act. Applications to deprive people of their liberty had been submitted to the Local Authority. Staff sought the consent of people before providing care. Arrangements were in place to assess people’s capacity in relation to any complex decisions that they needed to make.

Families that we spoke with told us they thought the home was a safe place to live. They said there was good security in the home. We observed staff constantly checking on people throughout the day and supporting people in a safe way.

Staff could clearly describe how they would recognise abuse and the action they would take to ensure any concerns they had were reported. Training records confirmed the staff team was up-to-date with training in the safeguarding of vulnerable adults.

A process was established to manage and monitor accidents, including a process for analysing accidents on a monthly basis. We could see from the analysis that appropriate action was taken to minimise the risk of an accident happening again.

People and families were satisfied with the quality of the food and the choice of meals available. They told us the quality and choice of food had improved greatly.

People told us they had access to a range of health care practitioners when they needed it. Families confirmed this. We spoke with health care professionals who confirmed that they visited people living at the home on a regular basis. They told us the care provided was good but clinical care plans were not robust. We found clinical care records, including care plans related to clinical matters did not always reflect people’s current needs and these discrepancies had not been identified either though the provider’s external or internal auditing processes.

People told us they were happy living at the home. They said the staff were kind and caring and they had opportunities to join in recreational activities. Some people went out with the activity coordinator.

Arrangements to monitor the safety of the environment had improved. There were numerous audits and checks in place to monitor the safety of the environment, equipment and cleanliness. We found that the environment and equipment was clean, and well maintained. The manager was gradually developing the environment to ensure it was dementia-friendly. This development plan was on-going.

Staff, families and people living there said the manager was both approachable and supportive. They felt listened to and involved in the running of the home. People and families described the staff as caring, friendly and approachable and told us they were involved in developing and reviewing their care plans. This was confirmed from the care records we looked at.

People living at the home, families, staff and health care professionals said the home was well managed. They said the culture within the service was open and transparent and that the manager was both approachable and supportive. Staff were aware of the whistle blowing policy and said they would not hesitate to use it.

A procedure was established for managing complaints and people living at the home and their families were aware of what to do should they have a concern or complaint. No complaints had been received since August 2015.

Audits or checks to monitor the quality of care provided were in place and these were used to identify developments for the service. Some of the audits were not effective as they had not picked up on issues we identified. These included the medicines audit and care plan audits.

The provider was informing the Care Quality Commission (CQC) of all the events CQC are required to be notified about.

As part of the inspection we spoke with seven people who used the service, the manager, six care staff, two domestic staff and one nurse. We also reviewed records relating to the management of the home, which included seven care plans, daily care records, staff files and records relating to the management of the service.

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

Is the service safe?

People who lived at the home told us they were treated with respect and dignity by staff. People told us they felt safe and that if they had any concerns they would raise these with staff or with the manager.

The manager was aware of his responsibility to refer to external professionals if it was felt that a person may be being deprived of their liberty. However the manager failed to recognise potential safeguarding matters and therefore failed to follow appropriate safeguarding procedures to ensure people were protected from the possibility of abuse or neglect.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to residential services and care homes. While no applications have needed to be submitted, proper policies and procedures were in place. Records we reviewed confirmed that staff have been trained to understand the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards.

Is the service effective?

People told us that they were happy with the care they received and felt their needs had been met. It was clear from what we observed and from speaking with staff that they understood people's care and support needs and they knew people well. One person told us; "The staff couldn't do anything more for us." Another person commented; "It's really homely here, when families or friends visit they are always made welcome."

Is the service caring?

We observed that staff were kind and attentive when they supported people who used the service. We saw that care workers were patient and gave encouragement when supporting people. People who used the service told us that they were able to do things at their own pace and were not rushed. Our observations confirmed this. One person commented; "The girls are lovely, they are really good to me." A visitor told us; "Things are much better here now, I have no concerns about [her] care, it's a good home."

Is the service responsive?

We reviewed records which confirmed that people's individual needs had been assessed and that individuals had been involved in their own care planning. Records we reviewed confirmed people's personal preferences, interests and diverse needs had been recorded and care and support had been provided that met their wishes. People had access to activities and were able to maintain access to their families and friends.

Is the service well-led?

The provider had a system in place for checking on the quality of the service and this involved seeking the views of people who lived at the home on a regular basis. We reviewed records which confirmed that actions had been taken to make improvements to the service based on people's feedback. At the time of our inspection there was a manger in post at the service, who was able to confirm that he had started the process of registration with the Care Quality Commission.

We found that not all the required information about staff working at the home was available to show that they were fit and suitable to work with vulnerable people. The provider had been made aware of this following a safeguarding investigation carried out by the local safeguarding team however they had taken little action to address the concerns raised about staff recruitment.

People told us that there had been enough staff to meet their needs and that staff had responded promptly to their requests for assistance. We found that there was sufficient numbers of staff working at the home and that since our last inspection there had been significant improvements made in relation to staffing at the home. Staff told us that a number of permanent staff had recently been employed to work at the home which meant there had been no need to call upon agency staff.

We found there was a lack of robust systems to assess and monitor the quality of the service which resulted in issues and concerns not being identified and acted upon.

The management of records had improved since our last inspection visit. However we found further concerns with records including the lack of maintenance of records which were required by law.

We found that daily fridge temperatures had not always been carried out to ensure medications were being stored at the recommended temperatures to ensure their efficiency.

We did not see any evidence that staff had received appropriate training for handling and managing medicines safely or that staff had undertaken an assessment of competence to ensure they had the skills necessary to perform their duties safely.

We found that there was a lack of a robust audit system to ensure medications were safely managed.

We found that menus did not include a choice of nutritious food and drink and access to food of an evening and during the night was limited.

We saw staff rushing around and they told us they felt under pressure to meet people's needs. Some peoples care needs were not met in a timely manner because of insufficient staff on duty. The skill mix of staff was not appropriate to the needs of people who used the service. The high use of agency staff put people's health and safety at risk.

People who used the service were aware of the complaints procedure and some people told us they had confidence in using it whilst others told us they did not. People were advised by staff that they could make a complaint if they wished to however they were not provided with the appropriate support and assistance with complaints they had raised.

Records which were required for people who used the service had not been completed and maintained and staff did not have access to important records about people's care and welfare. We found some people's personal care records unsupervised in communal areas of the home.

People gave us mixed feedback about the quality of meals and food provided. People did have a choice of meals from a menu and people's requests for additional choices were catered for.

People told us they were happy with the home environment and the quality of furnishings provided in their own rooms and in communal areas.

The home environment was clean and appropriately presented overall but we noted areas for improvement.

The staffing levels were sufficient to ensure the needs of the people who used the service were met appropriately.

Records were generally appropriately maintained with the exception of care plans for people who used the service.

We used a number of different methods to help us understand the experiences of people living at Abbeydale Nursing Home. This was because many of the people using the service had complex needs which meant they were not able to tell us their experiences. However during our inspection we were able to speak with four people who used the service and a relative visiting the home. People we spoke with told us they were happy with the care they received. Some comments made included:

'We're well looked after here'.

'You can't fault the staff'.

We spoke with people about medicines handling at the home who told us they were happy with the arrangements in place for handling their medicines. One person we spoke with commented that staff 'don't leave them about' and they 'always check you've had them'. During our visit we found improvements had been made to ensure that medicines were safely administered and kept securely.

The people who used the service were cared for by staff that were appropriated recruited, trained and experienced at supporting them. Abbeydale Nursing Home monitored the quality of the service provided on a regular basis.