CQC report explained · a nursing home
What the CQC found at Abbotsleigh Mews Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, August 2023
Rated Good; inspectors found safer care and stronger management, with some weekend staffing pressures still worth asking about.
Inspectors visited on 5 and 15 June 2023. The inspection was unannounced on the first day. They spoke with people, relatives and staff, observed care, and checked care, medicines, staffing and management records.
The home was rated Good for Safe and Well-led. Inspectors found that risks were assessed and reviewed, medicines were managed safely, staff recruitment checks were completed and there were enough staff during the inspection. People and relatives generally said they felt safe and positive about the care.
The home had improved since the previous inspection, which was rated Requires Improvement and included breaches of regulations. The provider was no longer in breach at this inspection. However, this was a focused inspection of Safe and Well-led only, so the other question ratings were carried forward from the previous inspection.
Risk management
Care plans contained current risk information. Staff followed guidance for falls, nutrition, hydration and other identified risks.
“Risks to people were identified, assessed, documented and reviewed to ensure their needs were safely and appropriately met.” from the report
Safe medicines
People received their medicines as prescribed. Staff were trained and checks were carried out on medicines storage and administration.
“Medicines were safely managed and people received their medicines as prescribed.” from the report
Improved leadership
The home had new management since the previous inspection. Audits covered care records, medicines, staffing, incidents, complaints, safeguarding and call bells.
“The provider had systems in place which facilitated an effective oversight of the service in that it highlighted any omissions or errors.” from the report
People felt safe
People and relatives spoke positively about staff and said they felt safe. Safeguarding procedures and staff training were in place.
“People and their relatives spoke positively about the support they received to manage their risks and said they felt safe.” from the report
Weekend staffing
minorA staff member said that things did not always run as smoothly at weekends when management were not present. Some people also said waits could be longer after a fall.
“sometimes things do not run as smoothly at weekends when management are not there.” from the report
- 01How do you make sure staffing remains sufficient and organised at weekends?
- 02What happens if several people need help at the same time, or there is a fall?
- 03How are call bell response times monitored now, and what happens when a call takes longer than eight minutes?
- 04How will you maintain the improvements made to risk assessments, medicines and quality checks?
- 05What were the ratings for Effective, Caring and Responsive at the previous comprehensive inspection?
This was a focused inspection of Safe and Well-led only; the other key question ratings and parts of the overall rating were carried forward from the previous inspection. This explanation was written from the published report of 10 August 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, August 2022
Rated Requires Improvement; inspectors found ongoing risks with staffing, falls, choking, medicines and quality checks.
This was an unannounced focused inspection on 16 and 23 May 2022. Inspectors looked only at Safe and Well-led because concerns had been raised about choking, falls and safeguarding. They spoke with people, relatives and staff, observed care and mealtimes, and checked care plans, risk assessments, medicines, staff files and management records.
The home was not always safe. Risk plans for choking and falls were not always detailed or followed. Some staff could not explain modified food needs, one referral for swallowing support was delayed, and some people did not receive the supervision they needed while eating. Call bells were sometimes answered late, and one prescribed medicine had not been given for more than three weeks.
The home was also not always well-led. Its checks did not identify or fix several problems quickly enough. Inspectors did find improvements in infection prevention and control, safe recruitment, cleanliness, safeguarding and the way accidents were followed up. The overall rating remains Requires Improvement, as it was at the previous inspection.
Safe recruitment
The home carried out detailed checks before staff started work, including references, identity checks and DBS checks.
“The provider carried out comprehensive background checks of staff before they started work.” from the report
Infection control
Inspectors found the home clean and saw staff using suitable protective equipment. Improvements meant the home was no longer in breach about serious infection risks.
“We were assured that the provider was using PPE effectively and safely.” from the report
Safeguarding
People and relatives said people were safe. Staff had safeguarding training and understood how to report concerns.
“People and their relatives told us people were safe and that staff treated people well.” from the report
Accident follow-up
There were systems for reporting and reviewing accidents and incidents, and records showed appropriate action had been taken when needed.
“There were systems and processes in place to manage and follow up on accidents and incidents.” from the report
Choking and falls risks
seriousRisk plans were not always accurate or detailed. Staff did not always follow swallowing guidance, and referrals for specialist swallowing advice were not always made promptly.
“Risk management plans were not robust to mitigate potential risks to people.” from the report
Staffing and call bells
seriousStaff were not always deployed effectively. Inspectors found 274 call bell responses between eight and 134 minutes late over the period reviewed, and the delays had not been properly analysed.
“Call bells were not always responded to in a timely manner.” from the report
Medicines
seriousOne person had not received a prescribed medicine for more than three weeks. The home's regular medicines audits had not identified this problem.
“One person had not received their prescribed medicine for over three weeks.” from the report
Quality oversight
seriousThe provider's checks did not reliably identify or correct problems with risk management, medicines, staffing or call bell delays. Inspectors said this placed people at risk of harm.
“The provider did not have an effective oversight of the service.” from the report
Mixed day-to-day experience
needs fixingSome people and relatives reported limited activities, cold food, delayed personal care and concerns about agency staff. Others said the home was comfortable, friendly and well run.
“People gave a mixed response about how the service was run and the support they received.” from the report
- 01What has changed to make sure every person's choking and falls risk plan is accurate and followed at every meal and in communal areas?
- 02How many staff are planned for each house on day and night shifts, and how is this number calculated from people's needs?
- 03What system now checks that call bells are answered promptly, and what action is taken when delays happen?
- 04How do you make sure every prescribed medicine is given on time, including medicines needing support from district nurses?
- 05How do your quality audits now identify and fix problems before they put people at risk?
This was a focused inspection of Safe and Well-led only; the Effective, Caring and Responsive ratings used for the overall rating carried over from the previous inspection. This explanation was written from the published report of 26 August 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Abbotsleigh Mews Care Home
6 rated inspections over 7 years: the service has improved, from Requires improvement to Good.
- August 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2022Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- December 2020Requires improvementdown from GoodSafe: Inspected but not ratedWell-led: Requires improvement
- October 2019Goodstayed GoodSafe: Requires improvementWell-led: Good
- April 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2016Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Good
- March 2014
Report published without a new overall rating.
- December 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- March 2012
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 16 November 2010.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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