Abbey Grange Care Home

The following is CQC's published account of its assessment, published 30 October 2025. References to “we” mean CQC. It describes findings at that time.

This comprehensive assessment was undertaken between 29 and 30 September and 1 October 2025. We assessed all quality statements under the five key questions of Safe, Effective, Caring, Responsive and Well Led. This assessment was undertaken to follow up the last assessment where high level enforcement action was commenced. This assessment was undertaken to check the actions the nominated individual had taken since our last assessment.

The service is registered to provide accommodation for persons who require personal care for up to 25 older people. There were 9 people living in the service at the time of the assessment.

The last rating was inadequate overall and inadequate in Safe, Effective and Well-Led and requires improvement in Caring and Responsive. At the last assessment we found 7 breaches of the legal regulations in relation to, person centred care, medicines management, infection prevention and control, risk management, the environment and equipment. We also identified concerns in relation to Mental Capacity Act (MCA), Deprivation of Liberty Safeguards (DoLS) and consent as well as the management of safeguarding, the management of nutritional needs, records and the operation and governance of the service, the knowledge, skills and oversight of the management and staffing, training and recruitment practices. We also identified concerns in relation to person-centred care and safe care and treatment. At this assessment we found that the service had acted on the concerns identified at the last assessment and we found significant improvements had been made and the service was no longer in breach of legal regulations.

This service has been in Special Measures since 15 May 2025. The provider demonstrated improvements that have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

The service made sure medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in assessing and planning people’s care, including when changes happened. Electronic records had been updated to include individual risks and how to support them. Improvements had been made in relation to the environment, servicing and checks had been undertaken and audits were ongoing. People had access to a range of professionals to support them with their individual needs.

Infection prevention and control practices have improved since the last assessment and information, guidance and personal protective equipment to support infection prevention was available to the staff team. Records in relation to safeguarding had been developed, where these required evidence of lessons learned was seen but these needed to be improved, the provider took immediate action to address this. Staff had undertaken a wide range of training and supervisions were ongoing. Improvements in the recruitment processes was seen but further improvements were required in relation to confirming people were recruited safely, with the relevant checks.

A new electronic care planning system had been introduced and these included information about how to support people’s needs. Staff confirmed care records were developed and reviewed by the management team. Records included information that confirmed consent had been sought from people and DoLS applications had been submitted to the assessing authority. Approved applications were reflected in care plans; the provider took action to ensure bedrails for one person’s bed was put in place immediately in line with their DoLS authorisation. People were supported to make important decisions about their end of life wishes.

An effective system for ensuring people were supported to access a range of meals and choice was taking place, records included information about the involvement of professionals and information, evidence confirmed they had been engaged and involved in people’s needs. A range of guidance, information and policy was available to support the staff team.

Records included information about promoting healthy lifestyles. We saw people taking part in exercise sessions and 1 person regularly visited the local gym. Staff treated people with kindness and respect, and staff protected people’s dignity. People’s individual needs were met, and they were given choice in relation to their care.

Staff were supported and engaged by a management team that had made improvements since our last assessment, spot checks and supervisions were being undertaken that would ensure staff felt supported and engaged.

A range of information and guidance was on display, this included easy read and pictorial information that supported alternative ways of communicating. Complaints, comments and feedback was obtained, staff knew what to do to report a complaint. The service sought feedback in the form of surveys and questionnaires from a range of people.

People and relatives where overwhelmingly positive about the improvements that had taken place since our last assessment. Significant improvements since our last assessment were seen across all areas. The nominated individual discussed their commitment to continue to improve.

Audits and monitoring of the service was taking place and senior audits had been done recently. Notifications were being submitted to the Care Quality Commission. Staff understood their roles and responsibilities, and positive feedback was received about the management team and the changes they had made since our last assessment. Staff had been allocated champion roles in a number of areas; this meant they were able to share their knowledge and understanding with the staff team. Information guidance and registration certificates were on display in the entrance. We discussed the importance of ensuring the services ratings was on display in the communal areas. The nominated individual gave assurance that this would be on display at all times, we saw this was displayed in the entrance during the assessment.

Team meetings confirmed staff were engaged and involved, a range of up-to-date policies and procedures were in place to support and drive improvements.