Abbotsleigh Mews Care Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

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.

The manager had clear values which were shared with the staff, and they provided training and support to enable staff to work towards these. The manager told us their aim was to help people live a healthier happier longer lives. They wanted to see kind care, staff doing the basic things that made the big difference in people’s lives.

Staff told us they felt happy and supported working at the service. A staff member told us, “Staff and managers work hand in hand to make sure people are safe and their needs are being met.” Another staff member said, “The manager is amazing, the best we have had, she listens and is very supportive easy to approach.”

There were capable and inclusive leaders. The manager had managed the service for 6 months. They had applied to the CQC to become the registered manager for the service. The manager told us they felt well supported by senior managers. The regional director visited them each week to provide 1-1 support and to help to improve the quality of care at the service. The regional support manager also visited the service each week to offer support. The manager also attended regular managers meetings where they learned about and shared good practice.

The manager was knowledgeable about their responsibilities regarding the Health and Social Care Act 2014. They were aware of the types of significant events which they were required to notify CQC about and records showed the service had submitted notifications to CQC where needed.

There was a management structure in place. Staff were positive about how the service was run and about the support they received from the manager. One staff member told us, “There has been lots of improvement since the manager came here, she is on the ball, open and candid, she is respected, and the happy atmosphere is back. All the positive changes are down to manager, she knows all the staff and the residents’ names, she has a person-centred approach.” Another staff member said, “I love working here. The manager is superb, very supportive.”

Management support was available for staff when they needed it. The manager told us there was a 24 hour on-call number where staff can contact managers if they need any advice or support. A staff member told us, “We can call managers at any time if there is an emergency at the home.”

There were regular staff meetings in place to support and guide staff with best practice. Staff told us they were able to express their views at these meetings and they felt they were listened to. One staff member told us, “The team meetings are good. We get to express ourselves, bring ideas and share good practice.”

There were systems to enable staff and others to speak up when something was wrong. Staff told us they felt confident speaking up. One member of staff told us, “I know about the providers whistleblowing procedure, and I will use it if I need to report any poor care practice.”

The provider supported staff to feel included and treated them with equity, taking account of their individual needs. A staff member told us, “We have staff from different cultures and races, but we all use a common language, we all work together as a team. There are procedures in place to prevent staff from being bullied or harassed.” Another staff member told us, “We as staff are well looked after and care for. We have a free meal each day which is great. I left and wanted to come back because the manager had made so much improvement. I love working here. When I come the manager is always happy to see me.”

The provider had a quality improvement plan in place. This covered areas such as staff training needs, care plan reviews and Mental Capacity assessments. We also saw a quality metrics report from January - March 2025. This covered areas such as accidents and incidents, falls analysis, medicines errors, complaints, safeguarding referrals, and lessons learned. The manager told us they received the metrics pack monthly to analyse the data. Actions were taken to make the service safer, for example, care plans were reviewed following any falls or incidents and accidents. The regional team also reviewed the data. This added another layer of governance to ensure the safety of people living at the home.

We saw a report from an unannounced nighttime spot check carried out at the service in March 2025. The manager told us these checks were carried out to make sure people were receiving consistent quality care and to speak with staff about any nighttime support needs. Where shortfalls occurred the provider to action, for example, increased unannounced night visits for closer monitoring.

We saw a report from a satisfaction survey carried out with people and their relatives. This indicated that people and their relatives were happy with the care and support they were receiving. Where people referred to minor shortfalls, the reported indicated what the service was doing to improve their performance.

Checks and audits were in place to oversee good service delivery and ensure people’s safety. Monthly audits covered areas such as care plans, health and safety, medicines, infection control, mealtime satisfaction, complaints, accidents and incidents and. Monthly checks were carried on equipment such as wheelchairs, hoists and call bells.

The manager told us they worked in partnership with other organisations. These included the local authority’s dementia care and palliative care teams, physiotherapists, speech and language therapists and diabetic nurses. The activity coordinator was working on a partnership with the Salvation Army. A local optician visited some people at the service.

The palliative care team was based at the service once a month and offered coaching sessions to staff. The manager told us the local authorities complex care team had been very helpful in supporting people and staff at a unit at the service. The local authority also facilitated training for staff on oral health and end of life care.

An officer from the local authority that commissions services told us the home had been under a provider concerns process since 2023. Since the managers arrival in September 2024, they had seen positive changes in the service with focus on a service improvement plan. The manager and management team had engaged in the provider concerns process during their visits.

There were systems for learning. These included regular training sessions for staff, meetings and staff supervisions. The manager discussed learning from accidents, incidents and complaints with staff. There was a service improvement plan which was regularly reviewed and updated. There was evidence of learning and improvements.