Abbotsleigh Mews Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There was a positive and proactive learning culture, and managers and staff communicated effectively to help drive improvements. People and their relatives told us they attended meetings in which their feedback was encouraged. One person commented, “There was one recently, it was well attended and lively with good results on the catering.”

There were clear policies and procedures in place for responding to incidents, accidents and complaints and staff we spoke with were knowledgeable about these. One person using the service told us, “I have got a leaflet that tells me how to complain, but I don’t have anything to complain about.”

Regular staff meetings were held which provided staff with information regarding any service improvements and lessons learnt. Records confirmed this and showed that following investigations, changes were made where required and reviewed to ensure they were embedded.

There were systems in place to ensure safe transitions and pathways for people. Assessments of people’s needs, risks and wishes were completed upon admission to the service and continually reviewed to ensure they were reflective of people’s needs. Care plans were developed and shared with health and social care professionals when required to ensure individuals continued well-being. Staff worked effectively with health and social care professionals to ensure people received appropriate support when meeting their physical and mental health needs. These included GP’s, hospital staff and community mental health teams amongst others.

People were supported to stay safe and were protected from abuse and avoidable harm. People told us they felt safe, and staff were readily available when required. Comments included, “I do feel safe, there is always someone there to help me if I need it”, “I do feel safe, I had a fall a little while ago and they [staff] were so quick to help me and see that I was alright, that was very reassuring”, and, “I feel safe, I have nothing to be anxious about, I have all my needs met.”

There were safeguarding policies and procedures in place and staff were trained to recognise and respond to concerns, potential abuse and harm. There were clear reporting mechanisms in place, and the management team demonstrated a proactive approach to safeguarding and the management of concerns. Staff told us they felt confident any concerns would be managed appropriately, and referrals were made to the local authority safeguarding team when required. There was good oversight of all safeguarding concerns and accidents and incidents. The home manager showed us a tracking tool used to manage these, and which supported the staffing team to learn when things went wrong. Records showed that appropriate actions were taken by staff where required following any adverse events.

Staff promoted people's rights and worked within the principles of the Mental Capacity Act 2005 (MCA). The MCA provides a legal framework for making decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires that, as far as possible, people make their own decisions and are helped to do so when needed. People and their relatives where applicable, were consulted and supported to make choices and decisions for themselves. Mental capacity assessments were completed where required and reviewed regularly to ensure they were reflective of people’s needs and wishes. The provider had requested legal authorisations where restrictions were in place. Decisions around these were made in people’s best interests and for their safety.

Risks to people’s safety and wellbeing were assessed and planned for. People and their relatives told us they were involved in planning and managing identified risks. Comments included, “I was involved in discussions and also had a large form to fill in”, “I helped with [loved ones] care plan though we tried to involve [loved one]”, and “I was involved because I help [loved one] with their food when I am here. They [staff] talked me through the right way to do it and what risks there are.”

Comprehensive risk assessments were completed with people, with care plans developed following assessments to mitigate identified risks. For example, risk of falls, skin integrity and nutrition and hydration. Regular reviews of risk assessments and care plans were completed to ensure they remained reflective of people’s needs and effective in helping people to keep safe.

A visiting professional to the service told us, “Staff have a weekly clinical risk meeting and daily huddle meetings to help improve communication and to review any risk.” A member of staff told us, “We have regular team meetings where we can share ideas and raise concerns. It's good to know everyone's on the same page.”

The design of the premises was safe and met people's needs. People and their relatives told us they liked the home environment. Comments included, “I have this wonderful room where I have a perfect view of the garden which I can go to when the weather is warm. The place is spacious with private space if you need it and my little library”, “I like my room and there is plenty of space and I love the garden”, and “I use a walker and it is easy because there is no carpet so nothing to fall over.”

People had their own bedrooms which they personalised with furniture and belongings. People had equipment they needed to help keep them safe, such as hoists, walking aids, and bath and shower equipment. These were regularly checked to make sure they were safe to use. People had individual emergency evacuation plans in place which highlighted the level of support they required to evacuate the building safely in the event of an emergency.

The provider assessed and maintained the environment and equipment used. For example, fire alarm system, portable appliances, gas safety and water legionella testing. Checks and audits were also carried out on the call bell system and regular fire drills were conducted.

We spoke with the gardener; they ran a gardening club with people using the service. We saw a garden with raised beds and plants where people were able to grow sunflowers, runner beans and plant bulbs in the Autumn. The gardener told us they had entered the home into annual gardening competitions and showed us trophies and gold medals the home had won consecutively for the last 13 years. Care staff told us regular garden parties were held, and these were well attended by people and their friends and relatives.

There were no restrictions placed on visitors, and we observed relatives, friends and people visiting the service freely throughout our assessment. One person said, “My family and friends are in and out whenever they can.” A relative commented, “We come whenever we want and as you can see there is no limit to numbers.”

We observed there were enough staff deployed throughout the service to meet people’s needs when required. People and their relatives told us they felt there was enough staff to meet their needs in a timely manner. Comments included, “There are enough for them to pop in and chat sometimes”, “Yes, they can get busy at times”, “My [loved one] rarely asks for help but if we ask, they come quite fast.”

Staff told us they felt well supported within their roles. Comments included, “Compared to other places I've worked; this care home is brilliant. They actually care about us”, “Supervision is regular and helpful. It's not just a tick-box exercise; we discuss things that are going well and things I'm finding challenging.”

Staff told us they had received training in relation to peoples care and support needs. They told us they were up to date with training the provider considered was mandatory. One staff member told us, “I completed an induction and all my mandatory training, if you don’t do your mandatory training, you are not allowed to work here. The training was good.” Another staff member said, " I had training on dementia awareness. This gave me more knowledge on how to support people living with dementia and a better understanding of what they need. The training was very useful."

We saw a training matrix which indicated that staff had completed training in areas such as falls prevention, fire safety, basis first aid, infection control, medication administration, moving and handling, safeguarding adults, the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). Nursing staff had also completed training on diabetes, skin care, end of life care, venepuncture and catheterisation.

Robust recruitment procedures were in place. Recruitment records included proof of identification, application forms with employment histories, employment references, occupational health and right to work in the UK checks. Nursing staff’s National Midwifery Pin numbers were also sought and recorded. We saw evidence that Disclosure and Barring Service (DBS) checks had been carried out.DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

There were systems in place to help prevent and control infections. People told us they were happy with the home environment. Comments included, “It is very clean and well maintained”, “Cleaners are always here somewhere”, and “Its always nice and clean, I’m very happy with it.”

The provider employed domestic staff to oversee cleaning and laundry and there were regular audits of cleanliness. We noted a malodour in one of the units in the morning. We revisited the same unit later that day and the malodour had gone. A member of the housekeeping team told us they followed a cleaning schedule every day. They were mindful of the spread of infections and told us how they cleaned handrails and high touch areas. They told us they kept communal areas and people’s bedrooms clean and free from malodours.

The manager told us the head housekeeper and the deputy clinical manager were infection prevention and control lead at the home. They were responsible for making sure staff followed safe infection prevention procedures and carrying out infection control audits. We saw an infection control audit and action plan for March 2025. A member of the housekeeping team told us the housekeeping supervisor ‘was amazing and very supportive.’

Staff were provided with personal protective equipment (PPE) when needed. We saw they wore this appropriately. Training records confirmed that all staff had received training on infection control.

People received their medicines safely and as prescribed. People told us they were happy with the management of their medicines. Comments included, “I don’t have many medicines but they [staff] give them to me at the same time every day”, “Even my eye drops are done on time”, and “Regular as clockwork.”

Staff received up to date medicines management training and their skills and competencies were reviewed on a regular basis to ensure continued safe practice. Staff demonstrated a good understanding of medicines management principles and were knowledgeable about the medicines they administered.

Medicines administration records were kept on an electronic medicines management system which staff updated on a regular basis. Risks assessments and information about the different medicines people were prescribed were completed. Medicines audits were conducted on a regular basis by the management team. We saw medicines were stored safely and securely, with no excess medications observed in communal areas or people’s rooms. Stock control measures were in place to prevent the accumulation of expired or unwanted medications.