Abbot Care Home

At our last inspection (report published 11 May 2024) we found a breach of regulation. This inspection was to follow up on previous enforcement action that was taken during our previous inspection. At this assessment whilst some improvements had been made relating to the previous breach, further concerns were identified and 3 breaches of regulations related to person centred care, safe care and treatment and governance were identified. This was a full comprehensive inspection.

Care records and care plans did not always provide an accurate or complete account of people's needs. There was not always a clear rationale recorded in care plans for why people were receiving care in bed.

People were not always supported in accordance with their individual care plans. Records relating to distressed reactions from people were incomplete and did not consistently demonstrate the use of person-centred strategies identified within care plans.

People did not always receive person-centred care that reflected their individual needs, preferences and assessed risks. Observations identified limited meaningful engagement, particularly on areas such as Moorhen, Kingfisher 1 and Kingfisher 2. We observed staff interactions often focused on completing tasks rather than promoting wellbeing, occupation and emotional support. However, we also saw some positive interactions throughout the home during our visits.

Whilst we identified there were enough staff to meet people's care needs during our onsite visits, staffing arrangements did not always allow sufficient time for meaningful engagement and personalised support. However, we did observe a very positive activity. The provider explained recently members of their activity/lifestyle team had left, and they had recruited new staff into these roles.

Governance systems were not consistently effective in identifying and addressing these issues. Audits completed by the provider had not identified several concerns found during inspection, including care planning inconsistencies and documentation gaps. Incident analysis did not always identify all themes and trends, there was limited evaluation of whether actions taken had been effective, and no meaningful analysis of distressed reaction monitoring records were evident. However, the senior team responded proactively to our feedback and were actively addressing the issues identified within this report, including sending us a service improvement plan.

We also found examples of positive practice across several areas of the service. People were supported to access healthcare services when required, systems were in place to safeguard people from abuse, medicines were generally managed safely and minor issues found had now been resolved, infection prevention and control procedures were followed, and people and relatives were able to share feedback about the service.