# Abbeyfield Grove House - DCA

*Operated by Abbeyfield The Dales Limited.*

Abbeyfield Grove House - DCA is a CQC-regulated home-care agency in Ilkley.

## CQC Ratings

| Key question | Rating |
| --- | --- |
| Overall | Good |
| Safe | Good |
| Effective | Good |
| Caring | Good |
| Responsive | Good |
| Well-led | Good |

Rating published: 04/08/2018

## Practical info

- Postcode: LS29 9BF
- Registered manager: Downs, Fiona
- Local authority: Bradford
- Region: Yorkshire & Humberside
- City: Ilkley
- Last CQC check: 04/Aug/2018 - 00:00

## Inspection findings

### caring

- Finding
  - Involvement in care planning
  - Published: 2021-10-30
- Finding
  - Dignity, respect and person-centred approach
  - Published: 2021-10-30

### effective

- Finding
  - Nutrition and healthcare referrals
  - Published: 2021-10-30
- Finding
  - Mental Capacity Act and consent
  - Published: 2021-10-30
- Finding
  - Staff training and supervision
  - Published: 2021-10-30

### Other

- Finding
  - Evidence: Annual surveys, resident/family meetings and a staff recognition ceremony demonstrated engagement and openness.
  - Published: 2021-10-30
- Finding
  - Evidence: Accidents and incidents were recorded and reviewed as part of the internal audit system.
  - Published: 2021-10-30
- Finding
  - Evidence: The organisation proactively recruited a new manager following the departure of the registered manager.
  - Published: 2021-10-30
- Finding
  - Evidence: People were supported to access advocacy services where needed.
  - Published: 2021-10-30
- Finding
  - Evidence: Staff showed good understanding of the Mental Capacity Act 2005 and consistently sought consent before providing care.
  - Published: 2021-10-30
- Finding
  - Evidence: Support plans were person-centred, regularly reviewed, and written in the first person.
  - Published: 2021-10-30
- Finding
  - Evidence: Staff demonstrated good knowledge of safeguarding procedures and knew how to report concerns.
  - Published: 2021-10-30
- Finding
  - Evidence: Sufficient staffing levels were maintained with robust recruitment and DBS checks in place.
  - Published: 2021-10-30
- Finding
  - Evidence: People consistently reported feeling safe and spoke highly of staff, describing them as kind, caring and reliable.
  - Published: 2021-10-30
- **record_keeping** _(minor)_
  - Evidence: we found some daily reports lacked detail about the level of care and support provided...no formal process in place for daily records once completed to be returned to the office for audit purposes.
  - Published: 2021-10-30
- **leadership** _(moderate)_
  - Evidence: the registered manager had also failed to escalate concerns to the senior management team to allow them to support the process of addressing shortfalls in medication practices.
  - Published: 2021-10-30
- **incident_learning** _(moderate)_
  - Evidence: [Name of registered manager] was alarmed by the number of med errors they were coming across...dates still not being put on creams, eye drops and Paracetamol not in original containers.
  - Published: 2021-10-30
- **governance** _(critical)_
  - Evidence: although the shortfalls in the medication system had been identified by the organisation prior to the inspection no action had been taken to ensure people received their medicines safely.
  - Published: 2021-10-30
- **medication_management** _(critical)_
  - Evidence: Lorazepam 1mg tablets...had been left along with other medicines and creams on the unit top in the kitchen area of their apartment. They were not recorded on the MAR.
  - Published: 2021-10-30
- **medication_management** _(critical)_
  - Evidence: staff had not always completed the MAR correctly by signing each time they administered medicines or entering a code if for any reason people did not take their medicines.
  - Published: 2021-10-30

### responsive

- Finding
  - Daily record keeping
  - Published: 2021-10-30
- Finding
  - Complaints handling
  - Published: 2021-10-30
- Finding
  - Assessment and care planning
  - Published: 2021-10-30

### safe

- Finding
  - Risk assessments
  - Published: 2021-10-30
- Finding
  - Staffing levels and recruitment
  - Published: 2021-10-30
- Finding
  - Safeguarding people from abuse
  - Published: 2021-10-30
- Finding
  - Medication management
  - Published: 2021-10-30

### well_led

- Finding
  - Stakeholder engagement and transparency
  - Published: 2021-10-30
- Finding
  - Quality assurance and audit effectiveness
  - Published: 2021-10-30
- Finding
  - Registered manager in post
  - Published: 2021-10-30

## Source

Data published by the [Care Quality Commission](https://www.cqc.org.uk/) under the Open Government Licence v3.0. Canonical page: https://homecarecompass.co.uk/agency/1-2540377052

HomeCare Compass is an independent guide and is not affiliated with the CQC.