CQC report explained · a residential care home
What the CQC found at ABI Homes - Dyers Mews
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, December 2019
ABI Homes - Dyers Mews was rated Requires Improvement; care was safe, kind and personalised, but legal paperwork and quality checks were not always reliable.
The inspection took place on 11 November 2019. One inspector spoke with people living at the home, relatives, staff and managers. They reviewed care plans, recruitment and training records, medicines records, policies and quality checks.
The home was rated Good for Safe, Caring and Responsive. Inspectors found safe staffing, suitable medicines arrangements, kind staff, personalised care and support for people's communication, choices and activities.
The home was rated Requires Improvement for Effective and Well-led. One person did not have the required DoLS application despite being subject to the same restrictions as others. Some mental capacity records were unclear or conflicting, and audits had not found these problems.
The overall rating fell from Good at the previous inspection on 14 July 2017. The report says the home was open about the issues and intended to put the correct applications and documents in place immediately.
Safe care and staffing
Staff understood safeguarding and risk procedures. Staffing levels matched people's assessed needs, including one-to-one support where required.
“Staffing levels matched the support that people required.” from the report
Kind and respectful staff
People and relatives described staff as caring and respectful. Staff took time to understand how people communicated and wanted to be supported.
“We saw staff with people, giving them the time they needed to communicate and express themselves.” from the report
Personalised support
Care plans included people's preferences and ways of being supported. People were helped to take part in activities, employment opportunities and decisions about staff recruitment.
“The care plans provided good information about people's individual needs.” from the report
Communication support
The home adapted information using pictures, signing and social stories. This helped people understand events and reduce anxiety.
“Social stories were used to help people understand different situations, and reduce anxiety around new environments and people.” from the report
Safe medicines arrangements
Medicines were securely stored and administration records were accurate in the records inspected. Instructions for medicines taken when needed were detailed enough to guide staff.
“All medicine administration records (MAR) we looked at were used correctly and medicine stock was accurate.” from the report
Missing DoLS application
seriousOne person was subject to restrictions but did not have the required DoLS procedure applied for. This meant the legal paperwork did not consistently support the restrictions used to keep people safe.
“We found that one person did not have a Deprivation of Liberty Safeguards (DoLS) procedure applied for, despite being under the same restrictions.” from the report
Unclear capacity assessments
seriousSome mental capacity assessments were not clear and contained conflicting information about a person's ability to make decisions.
“We found some assessments to contain conflicting information about a person’s capacity to make a decision.” from the report
Audits missed problems
needs fixingThe home's quality checks covered many areas but did not identify the errors in mental capacity and DoLS records. This reduced confidence that the management systems would reliably find and correct issues.
“These audits were not always effective, as errors and omissions within the MCA and DoLS procedures had not been picked up.” from the report
- 01Has the missing DoLS application now been completed, and what restrictions does it cover?
- 02Have all mental capacity assessments been reviewed for unclear or conflicting information?
- 03What checks are now in place to make sure DoLS and mental capacity records are accurate and up to date?
- 04How do you make sure staffing levels continue to provide the one-to-one support people need?
- 05How are people and relatives involved in reviewing care plans and decisions about their support?
This was a planned inspection covering all five CQC questions and the overall quality and safety of the care home. This explanation was written from the published report of 11 December 2019 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, July 2017
Rated Good; inspectors found safe, kind and personalised care, with staffing gaps covered by agency staff and managers.
This was an unannounced inspection on 27 June 2017. One inspector spoke with one person, observed another person, spoke with staff and managers, and reviewed care records, staff files and other documents.
The home was providing accommodation and personal care for four people, although it could support up to five. Inspectors found enough staff to meet people's needs, safe medicines systems, suitable risk assessments and appropriate staff recruitment checks.
People were supported by trained staff who understood their needs. Inspectors saw respectful care, choices about food and daily routines, personalised care plans, support with activities, and systems for handling complaints.
The home was rated Good in all five areas and overall. It remained Good, as it had been at the previous inspection in March 2016.
Safe care and medicines
Inspectors found that people were protected from harm and received their prescribed medicines safely. Medication records and stock checks were accurate.
“People were consistently protected from the risk of harm and received their prescribed medicines safely.” from the report
Choice and independence
People were supported to make choices about their care, routines, food and activities. Staff used the least restrictive approach described in the report.
“People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible” from the report
Respectful relationships
Staff knew people well and treated them as individuals. Inspectors saw friendly interactions and respect for privacy.
“We saw that staff and managers all had a positive rapport with people, and people were comfortable around staff within the service.” from the report
Personalised activities
People were supported to follow their interests and take part in activities, including employment, a day service and bowling.
“We saw that each person had hobbies and interests documented within their care plans.” from the report
Complaints were acted on
The home had a complaints process, and inspectors found that complaints were recorded and dealt with appropriately.
“We saw that any complaints made were recorded and acted upon appropriately.” from the report
Staffing and management changes
minorThe home used agency staff and managers working shifts to cover staffing gaps, and recruitment was being planned. There had also been recent changes in the management structure, although staff said they felt supported.
“Gaps were filled by agency staff and managers also working shifts with people.” from the report
- 01How are staffing gaps and planned recruitment being managed now?
- 02How often are agency staff used, and how do you make sure they know each person's needs?
- 03Who is currently responsible for managing the home, and what cover is provided when the registered manager is away?
- 04Has the new care planning system mentioned in the report been introduced, and how does it improve people's records?
- 05How are families involved in reviewing care plans when a person cannot make decisions for themselves?
This was an unannounced inspection covering all five questions; the inspector spoke with one person, observed another, and other people were not available to speak during the visit. This explanation was written from the published report of 14 July 2017 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 ABI Homes - Dyers Mews
3 rated inspections over 4 years: the service has slipped, from Good to Requires improvement.
- December 2019Requires improvementcurrent ratingdown from GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2014
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 19 January 2011.
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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