CQC report explained · a residential care home
What the CQC found at 22 Levick Court
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from avoidable harm. Inspectors found appropriate risk assessments, enough staff, safe recruitment, safe medicines systems and effective infection prevention measures.
- Effective?
- Good
- This question was not inspected during this focused visit. Its previous rating was carried forward to calculate the overall rating.
- Caring?
- Good
- This question was not inspected during this focused visit. Its previous rating was carried forward to calculate the overall rating.
- Responsive?
- Outstanding
- This question was not inspected during this focused visit. Its previous rating was carried forward to calculate the overall rating.
- Well-led?
- Good
- Inspectors found effective governance, open communication and approachable leadership. However, staff supervision had not been completed regularly in line with the provider's policy.
What inspectors found, May 2023
Rated Good; inspectors found safe, kind and well-managed care, with staff supervision not always completed regularly.
This was a focused inspection. Inspectors reviewed Safe and Well-led, visited the home on 24 April 2023, spoke with people, relatives, staff and professionals, and checked care, medicines, recruitment and management records.
The home was rated Good overall, with Safe and Well-led also rated Good. Inspectors found enough suitable staff, safe medicines systems, appropriate risk assessments and effective infection control. People were treated with dignity, supported to make choices and helped to live meaningful daily lives.
Staff had not received regular supervision in line with the provider's policy, but the manager had recognised this and was taking steps to address it. The other three question ratings were carried forward from the previous inspection rather than reassessed.
Enough suitable staff
There were enough staff to meet people's needs, and recruitment checks were completed to help ensure staff were suitable.
“There were enough staff to meet people's needs. The numbers and skills of staff matched the needs of people using the service.” from the report
Safe medicines and risk management
Risks were regularly reviewed and medicines were administered, recorded and stored safely. Staff also followed principles intended to avoid excessive medicines use.
“Staff followed systems and processes to administer, record and store medicines safely. Medicine audits were carried out to ensure medicines were managed safely.” from the report
Choice and meaningful activities
People were supported to make daily choices, personalise their rooms and use a sensory room freely.
“People benefitted from the interactive and stimulating environment. There was a sensory room available for people to access freely.” from the report
Positive relationships
Inspectors found that people were treated with dignity and respect, and that care was tailored to their needs.
“There were positive relationships between people and staff, which meant people were treated with dignity and respect.” from the report
Effective management
The home used audits and other governance systems to monitor quality, risks and people's rights. Relatives and staff described the manager as approachable and supportive.
“Governance processes were effective. These processes helped to keep people safe, protect people's rights and provide good quality care.” from the report
Staff supervision
needs fixingStaff had not received regular supervision in line with the provider's policy. The manager had identified this and had measures in place to address it.
“However, staff had not received regular supervision in line with the provider's policy.” from the report
Size of the building
minorThe home was larger than recommended by current best practice guidance. Inspectors noted that it had been separated into smaller living areas.
“The service was larger than recommended by current best practice guidance.” from the report
- 01How have you made sure staff now receive supervision regularly and in line with your policy?
- 02How do the smaller living areas work in practice for the people who live here?
- 03How are people's risk assessments reviewed when their needs or risks change?
- 04How do you check that medicines continue to be reviewed and used safely?
- 05How will relatives be kept informed about changes, appointments or incidents?
This was a focused inspection of Safe and Well-led only; the other ratings were carried forward from the inspection published in April 2018. This explanation was written from the published report of 17 May 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, April 2018
22 Levick Court is rated Good overall, with Outstanding responsive care and some records and checking issues found.
Inspectors visited on 6 and 26 March 2018. The first visit was unannounced. They reviewed care and medicine records, staff files and management records. They observed people and spoke with people, relatives, staff and professionals.
The home was rated Good for Safe, Effective, Caring and Well-led. It was rated Outstanding for Responsive. Inspectors found personalised care, kind staff, suitable activities and strong support for young people moving from children's to adult services.
There were some areas to put right. Formal mental capacity assessments and best-interest decisions were not always recorded. Medicine competency checks were overdue, one person's weight loss had not been referred to the right professionals at first, and some audit systems needed improving.
The overall Good rating means the home met the expected standard overall at this inspection. The overall rating stayed Good from the previous inspection in October and November 2015, while Responsive improved to Outstanding.
Personalised support
Care plans were detailed and staff understood people's needs, preferences and goals. Support was adapted to each person, including people with complex needs.
“Support was totally tailored to each individual, and staff understood the best way to support each person with their complex needs.” from the report
Activities and independence
People had regular activities, outings and holidays based on their interests. Staff also encouraged people to make choices and develop their independence.
“A fundamental aim of the service was to promote people's quality of life by providing positive opportunities for people to live life to the full.” from the report
Kind and respectful staff
Inspectors saw staff treating people with kindness, patience and understanding. People were supported with their choices, dignity and emotional needs.
“Staff listened to people and made time for them to express their wishes in their own way.” from the report
Accessible communication
Information was provided in different formats, including pictures and large print. The home had developed pictorial information to help people understand care and health procedures.
“Information was available in different formats, large print, different languages, braille and pictorial format.” from the report
Medicine competency checks
needs fixingStaff had been trained to give medicines, but the manager's checks of their competency were overdue at the inspection. The manager said these checks would be completed within the next few weeks.
“The registered manager told us they checked staff competency to administer medicines but this was overdue” from the report
Mental capacity records
needs fixingFor some people who did not always have capacity, decision-specific assessments and best-interest decisions had not been completed for areas such as healthcare, personal care, medicines and equipment.
“For people who did not always have capacity, staff had not completed mental capacity assessments or best interests for areas such as choices about healthcare, personal care, medicines and equipment to be used.” from the report
One missed health referral
needs fixingOne person who had lost weight was not referred to the appropriate professionals at first. The manager said this had been missed, but action had been taken and the person had gained weight.
“However, we did note that for one person who had lost weight the appropriate professionals had not been contacted.” from the report
Quality audits
minorThe home counted medicines but did not have a formal auditing tool for some other records and systems. The infection control audit also did not cover the environment at the time of inspection.
“The registered manager and other staff carried out a number of quality assurance checks and audits to monitor and improve standards at the service.” from the report
- 01Have all decision-specific mental capacity assessments and best-interest decisions now been completed for healthcare, personal care, medicines and equipment?
- 02Have all staff had their competency to administer medicines checked, and how often are these checks repeated?
- 03What process is now used to make sure weight loss leads to a prompt referral to the appropriate health professionals?
- 04What formal audits are now used to check care records, medicines and infection control?
- 05How would you plan a transition into the home for a young person moving from children's to adult services?
This was a comprehensive inspection covering all five rating areas, and the overall rating remained Good from the previous inspection while Responsive improved to Outstanding. This explanation was written from the published report of 21 April 2018 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 22 Levick Court
3 rated inspections over 7 years: the service has held its Good rating throughout.
- May 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: OutstandingWell-led: Good
- April 2018Goodstayed GoodSafe: GoodWell-led: Good
- December 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2014
Report published without a new overall rating.
- May 2014
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- July 2012
Registered with the Care Quality Commission on 12 July 2012.
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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