Updated 10 August 2023
Inspection team
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.
As part of this inspection, we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.
Inspection team
The inspection was carried out by 2 inspectors, a nurse specialist professional advisor and an Expert by Experience on the first day. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of service. 2 inspectors returned to the service on the second day.
Service and service type
Abbotsleigh Mews Care Home is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and we looked at both during this inspection.
This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the
quality and safety of the care provided and compliance with regulations.
At the time of our inspection there was a registered manager in post.
Notice of inspection
This inspection was unannounced. The provider knew we would be returning on the second day of the inspection.
What we did before the inspection
We reviewed information we had received about the service since the last inspection. This included any significant incidents that occurred at the service. The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report.
We reviewed the previous inspection report and actions plans submitted after the last inspection. We contacted the local authority commissioning and safeguarding teams to support our planning. We used all of this information to plan our inspection.
During the inspection
The inspection activity started on 5 June 2023 and ended on 15 June 2023. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. We observed mealtimes and interactions between people and staff.
We met and spoke with 6 people using the service and 2 visiting relatives about their experience of the care provided. We spoke with 24 members of staff, this included the provider’s regional director, clinical deputy manager, registered manager, home manager, deputy manager, nursing staff, care staff, activities coordinator, kitchen staff and housekeeping.
We reviewed a range of records including 14 people's care and medicines records and 6 staff files in relation to recruitment, training and supervision. We also reviewed records related to the management of the service, including incident reports, complaints, quality assurance, health and safety checks and minutes of a range of meetings held across the service.
We observed staff daily meetings and carried out observations throughout the inspection in relation to infection prevention and control procedures and practice. We continued to seek clarification from the provider