This unannounced comprehensive inspection took place on the 15 October 2018. The inspection team consisted of two inspectors.

Abbey Park House 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 Park House accommodates up to 28 people in one adapted building. Eighteen people lived at the home at the time of our inspection visit.

At our last inspection in January 2017 we judged the home to be ‘requires improvement’ in the key questions of safe, effective, responsive and well-led. We found the service to be in breach of regulation 17: Good governance. The systems in place to monitor and improve the quality of the service were not robust and had failed to ensure people received safe and a good quality of life.

This inspection took place on 15 October 2018 to follow up on our previous findings. We returned on this occasion to check whether people were safe and that the provider was taking the necessary action to improve the quality of care and reducing the risks to people. We found the service had not improved following our last inspection and had deteriorated. We also identified breaches of regulations 9, 10, 12, 13, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, in addition to regulation 18 of the Care Quality Commission (Registration) Regulations 2009. We have considered that those breaches of regulation were exposing people to the risk of unsafe or inappropriate care. We are considering what further action to take.

There was a registered manager in post at the time of the inspection. 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 not always kept safe because risks were not always assessed, monitored or mitigated. People were not protected by the provider's procedures for the prevention and control of infection. Environmental risks were not well managed or addressed in a timely manner. People were not always protected from the risk of abuse. Staffing levels were insufficient to meet people's needs in a timely manner. Accidents and incidents were not being consistently investigated and followed up. Where lessons could be learned to improve the service, and make the care people received safer; these were not always identified and addressed. People received their medicines as prescribed.

The provider's systems did not ensure staff had the skills, training, knowledge or experience to meet the needs of the people who lived at the home. People were not supported to have maximum choice and control of their lives and were not supported in the least restrictive way possible. The environment was not to a consistent standard to meet people’s needs and well-being. There was a lack of signage to assist people to orientate themselves around the home. Staff involved and consulted a range of health and social care professionals to ensure people's healthcare needs were met. However, the advice given by these professionals was not always followed, put into practice or reflected in peoples care records. People we spoke with told us they were supported to eat well in accordance with their preferences.

People told us that staff were kind and caring. However, people's dignity was not always maintained and respected. Staff did not have time to spend quality time with people. Staff did not have information about people's social history or interests and were task focused with their approaches and engagement with people.

People did not always receive care and treatment that was responsive to their needs or pr

We carried out an unannounced comprehensive inspection of this service on 4 and 5 January 2017. During that inspection we found the provider continued to be in breach of the regulation related to governance. This was because the systems in place to monitor and improve the quality of the service provided were not effective in ensuring the home was consistently well-led and compliant with regulations. Audits and analysis of incidents, feedback from people and outcomes from reviews had not been undertaken or were ineffective and had not been used to identify developments and improvements that were needed.

After our comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the continued breach of regulation. We also met with the provider to discuss our concerns about the service and to hear about the improvements they planned to make. As a result we undertook an unannounced focused inspection on 16 May 2017. This report only covers our findings in relation to the key question, ‘WELL-LED’. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Abbey Park House on our website at www.cqc.org.uk.

Abbey Park House is registered to provide personal care and accommodation for up to 25 older people. At the time of our inspection 23 people were living at the home.

At this focused inspection we found that although improvements had been made and the registered provider was no longer breaching this regulation further action was still required.

There was not a registered manager for the service. There had not been a registered manager since August 2016. The previous deputy manager had been promoted to manager and they told us they were in the process of becoming registered. We saw they had submitted their application to register. We spoke with the manager during our inspection. 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.

We found that whilst there were some systems in place to monitor and improve the quality and safety of the service provided, these were not always effective in ensuring the service was consistently improving and compliant with the regulations. The registered provider had developed systems to record all accidents and incidents that had occurred at the home. However the records did not evidence that a detailed analysis had been carried out. People and staff considered the home to be well-led and the manager was described as approachable and supportive.

We inspected this home on 4 and 5 January 2017. This was an unannounced Inspection. The home was registered to provide personal care and accommodation for up to 25 older people. At the time of our inspection 21 people were living at the home.

We undertook a comprehensive inspection of this home in October 2015 when we had identified that improvements were needed throughout the service. We judged the home to require improvements in three of our key questions. The provider had breached the regulations in relation to consent and good governance. We undertook a focussed inspection in May 2016 to look specifically at the key question of 'safe.' This identified a breach of the regulations regarding safe care and treatment. We received an action plan from the provider on the actins they intended to take to meet the regulations. Our inspection in January 2017 found that improvements had been made in relation to the need for consent but that there continued to be a breach of the regulation related to governance.

There was not a registered manager for the service. There had not been a registered manager since August 2016. The previous deputy manager had been promoted to manager and they told us they were in the process of completing their application to register. 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 all of the people, relatives and visitors we spoke with were very complimentary about the home we did identify that people were not always protected by safe practices or effective risk management at the home and action was not always taken to learn lessons from incidents occurring at the home.

We found that whilst there were some systems in place to monitor and improve the quality of the service provided, these were not always effective in ensuring the home was consistently well led and compliant with regulations. Audits and analysis of incidents, feedback from people and outcomes from reviews had not been undertaken or were ineffective and had not been used to identify developments and improvements that were needed.

You can see what action we told the provider to take at the back of the full version of the report.

People were usually supported to maintain good health but in some instances the appropriate advice had not been sought in a timely way and this put people at risk of ill health.

We saw plans had not been reviewed in a meaningful way or in consultation with people and others that matter to them. There was a lack of varied activities and stimulation that were needed to reflect people’s individual interests and meet people’s specific dementia care needs. We have made a recommendation that the provider needs to take account of relevant good practice guidance in relation to supporting people with dementia to do things they enjoy. We did not see that adequate arrangements were in place to ensure the environment met people’s dementia care needs. We have made a recommendation that the provider takes account of good practice guidance in relation to a providing a suitable environment for people living with dementia.

People told us they felt safe living at the home. Staff we spoke with had knowledge of possible signs of abuse and could describe the action they would take in reporting any concerns. There was enough staff available to meet people’s requests for support. Recruitment checks were in place to ensure new staffs was suitable to work with people who needed support.

Staff told us they received the training they needed to meet people’s needs. There was no evidence of any competency assessments being carried out after training had taken place.

People were offered choice in aspects of their care, and the service had consist

We carried out an unannounced comprehensive inspection of this service on 21 October 2015. After that inspection we received concerns in relation to the safety of the service. As a result we undertook a focussed inspection of this service on 26 May 2016 to look into these concerns. This report only covers our findings in relation to the key question, ‘SAFE’. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Abbey Park House on our website at www.cqc.org.uk.

Abbey Park House is registered to provide personal care and accommodation for up to 25 older people. At the time of our inspection 24 people were living at the home.

The home had a registered manager but they were unavailable on the day of the inspection. We spoke with the deputy manager during our inspection. 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.

There were ineffective systems in place to minimise risks associated with peoples’ care. Risk assessments and care plans had not been updated sufficiently to aid staff and ensure consistent care was provided. Where peoples’ needs had changed supporting documentation had not reflected these. Staff knew how to safeguard people from potential harm and abuse.

The systems in place to ensure safe storage and disposal of medicines that were no longer needed were not effective.

People and their relatives told us there were sufficient numbers of staff to meet people’s individual needs. The registered providers' recruitment process was robust to ensure suitable people were employed.

You can see what action we told the provider to take at the back of the full version of this report.

We found that people’s needs were assessed and care was planned and delivered in line with their individual care plan. Risks presented by people's needs and conditions were assessed and managed to balance safety with independence. People told us that they were well looked after at the home.

The home was an adapted three storey Victorian building. There was an ongoing programme of refurbishment and repair to keep the premises safe and comfortable. The home was warm and clean. A passenger lift and a stair lift enabled people to move about independently. The provider arranged for regular safety checks of the premises. People told us that their rooms were comfortable.

People had their health and welfare needs met by sufficient numbers of appropriate staff. Care assistants on duty were led by a manager and supported by ancillary staff. Staff spent time with people who needed assistance or encouragement to eat or to take their medicines independently. Care assistants held nationally recognised qualifications and people told us that staff treated them well and were very patient.

The service has a written statement of purpose. During our inspection we found that the services provided at the home reflected those described in the statement of purpose.

We found that any incidents or accidents involving a person who used the service had been properly recorded by staff and managers. No significant incidents had taken place that should have been reported to us but were not.

Most people were not able to tell us their experience of using the service because of their complex needs and conditions. We used a variety of ways to understand their experience through looking at records, talking with care workers, with the manager and the provider and using the Short Observational Framework (SOFI) for inspection.

We saw that care workers continually engaged with people when they helped them. They spoke to them with affection and good humour and often touched them in a reassuring way when they were near them. Workers knew the way that people communicated and this meant that they understood and responded positively when a person became agitated or distressed.

One person was able to tell us that they liked it at the home, they said that " The staff are lovely and kind to me. You only have to ask and they are always there."

We met everyone who currently lives at Abbey Park during our visit. Most people were able to comment about the support they receive, and feedback was overwhelmingly positive.

We saw and people told us that staff are most important to people feeling happy and settled. Some of the people have been supported by the same group of staff for many years. Comments included, "I like all these girls, they are all very kind to me", " She makes me laugh, she isn't stuck up, just really nice" and "They are all really good at helping us. When you need a little bit of help you can rely on them."

Abbey Park employs kitchen staff to prepare basic, fresh, homely food each day. People told us they really enjoy the food and comments included, "I enjoy all the food, yes the food is very nice." and "I like the meals very much."

The home is an adapted domestic building. People told us sometimes this means the lounge feels crowded. Generally people told us they felt warm, comfortable and at home. Relatives and people using the service told us the home was always clean. We observed this, and we did not notice any unpleasant smells.

We inspected this home on 21 and 22 October 2015. This was an unannounced Inspection. The home was registered to provide personal care and accommodation for up to 25 older people. At the time of our inspection 19 people were living at the home.

The registered manager was present during our inspection. 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.

We found that whilst there were systems in place to monitor and improve the quality of the service provided, these were not always effective in ensuring the home was consistently well led and compliant with regulations. Audits and analysis of incidents, feedback from people and outcomes from reviews had not been undertaken or were ineffective and had not been used to identify developments and improvements that were needed.

Assessments of people’s capacity to make decisions and determination of their best interests had not always been undertaken for some aspects of people’s care. Staff we spoke with had limited or no knowledge about their responsibilities to promote people’s rights in relation to Deprivation of Liberty Safeguards (DoLS) and had not received any training. Some necessary applications to apply for Deprivation of Liberty Safeguards (DoLS) to protect the rights of people had not been submitted to the local supervisory body for authorisation.

We found the provider was in breach of two Regulations. You can see what action we told the provider to take at the back of the full version of the report.

People we spoke with told us that they felt safe living at the home and relatives we spoke with confirmed this. We found that staff knew how to recognise when people might be at risk of harm and were aware of the registered provider’s procedures for reporting any concerns. People and their relatives told us that there were enough staff available to meet people’s individual needs safely.

People were supported by staff who had received training and had been supported to obtain qualifications. This ensured that the care provided was safe and followed best practice guidelines. Recruitment checks were in place to ensure new staff were suitable to work with people who needed support.

People usually received their medicines as prescribed; however, the management of medication was not always safe and improvements were needed. There were the potential for errors noted in respect of some medication administration where medicines were not needed routinely or were not in a monitored dosage system.

People’s needs had been assessed and person-centred care plans were available to inform staff how to support people in the way they preferred. Measures had been put into place to ensure risks were managed appropriately.

People’s nutritional and dietary needs had been assessed and people were supported to eat and drink sufficient amounts to maintain good health. People were supported to have access to a wide range of health care professionals.

People told us, or indicated that they were happy living at the home. We saw that staff treated people with respect and communicated well with people. People told us they wanted to go out more in their local communities. Some people were not offered the choice of social activities.

There was a complaints procedure in place and this was displayed in different formats to support people’s preferred way of communicating. People told us they knew who to speak to if they had any concerns. Relatives told us they knew how to raise any complaints and were confident that they would be addressed.