CQC report explained · a nursing home
What the CQC found at Alveston Leys Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Medicines, recruitment, risk assessments and infection control were generally managed safely, although some call bells were not answered promptly and some diabetes care information needed improvement.
- Effective?
- Good
- This key question was not inspected during this visit. Its previous rating was used in calculating the overall rating.
- Caring?
- Good
- This key question was not inspected during this visit. Its previous rating was used in calculating the overall rating.
- Responsive?
- Good
- This key question was not inspected during this visit. Its previous rating was used in calculating the overall rating.
- Well-led?
- Requires improvement
- Some audits were described as more of a tick-box exercise and did not identify problems with fire doors, window restrictors, cleanliness or thickener records. People, relatives and staff were positive about the manager and felt able to raise concerns.
What inspectors found, May 2023
Alveston Leys Care Home was rated Good overall; inspectors found safe, kind care, but leadership and quality checks require improvement.
This was an unannounced inspection on 18 April 2023. Inspectors spoke with people, relatives, staff and managers, and checked care records, medicines, risk management, recruitment files and quality checks. The inspection was prompted partly by concerns about care standards and staffing, but inspectors found no evidence that people were harmed because of those concerns.
People generally said they felt safe and well cared for. Inspectors found medicines were managed safely, staff were recruited appropriately, risks were assessed and infection controls were in place. However, some people experienced delays when they used the call bell, and inspectors found some information about diabetes care needed improving. This was corrected during the visit.
The home was rated Good overall and Safe was rated Good. Well-led remained Requires Improvement because some audits did not identify safety, cleanliness and record-keeping problems. The overall rating stayed Good, but the other key question ratings were carried forward from the previous inspection because they were not inspected this time.
Kind, personalised care
People and relatives were positive about the care and said they were involved in daily decisions. They also felt able to raise concerns and believed they would be listened to.
“People and relatives said they felt well cared for and involved in daily decisions.” from the report
Safe medicines
Inspectors found that medicines were stored and given safely. Staff were trained and their competence had been checked.
“People received their medicines safely.” from the report
Risk management
Risks such as falls were assessed, reviewed and linked to plans telling staff how to keep people safe. Staff shared important information at handovers.
“Risks for people were assessed, managed and reviewed.” from the report
Infection control
Inspectors were assured that the home had suitable arrangements for preventing and managing infections, including using protective equipment safely.
“We were assured that the provider was responding effectively to risks and signs of infection.” from the report
Delays answering call bells
needs fixingSome people said staff did not always arrive promptly when they called for help. Inspectors heard alarm bells ringing for periods of time and the manager agreed to review staffing at key points in shifts.
“Some calls for help were not always answered in a timely way.” from the report
Quality checks missed safety issues
seriousSome audits did not identify problems that inspectors found, including fire doors that did not shut correctly and unsuitable window restrictors. The provider said these safety improvements would be completed within three days.
“We found some of these checks were more of a tick box exercise rather than driving the changes needed.” from the report
Cleanliness and thickener records
needs fixingCommunal kitchenette areas were not clean enough. Inspectors also found missing checks and inconsistent records about thickener, although staff appeared to be thickening drinks safely.
“Housekeeping checks and kitchen checks were completed; however, cleanliness of communal kitchenette areas fell short of expected standards.” from the report
- 01How quickly are call bells answered now, and how do you check response times during busy parts of each shift?
- 02What changes have been made to ensure fire doors shut correctly and window restrictors are the correct type?
- 03How are communal kitchenette areas checked and kept clean?
- 04How do you record which thickener each person needs, when it was opened and whether it is still in date?
- 05What improvements have been made to diabetes care information on the residential unit?
This was a focused inspection of Safe and Well-led; the other key question ratings were carried forward from the previous inspection. This explanation was written from the published report of 5 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, February 2018
Rated Good overall; inspectors found kind, responsive care, but the home was not consistently well-led and records needed improvement.
This was a comprehensive inspection carried out over 19 December 2017, 20 December 2017 and 2 January 2018. Inspectors spoke with people living in the home, relatives, staff and managers. They observed care, reviewed care plans and records, and checked staffing, training, medicines and quality checks.
The home was rated Good for Safe, Effective, Caring and Responsive. Inspectors found enough staff, safe recruitment, suitable medicines systems and staff who understood safeguarding. People were supported by trained staff, involved in decisions, treated with kindness and dignity, and given care based on their needs and preferences.
Well-led was rated Requires Improvement. Some records about repositioning, food and drink, medicines, creams and tube care were incomplete or inaccurate. The home had quality checks, but action was not always taken quickly enough. Inspectors also found that some management staff were not visible enough to staff and relatives.
Improved staffing
Staffing levels had improved since the previous inspection. Inspectors found enough staff to provide safe and effective care, although agency staffing sometimes affected continuity.
“The staffing level is a huge improvement.” from the report
Kind and respectful care
Staff knew people well and adapted their approach to individual needs. Inspectors saw patience, reassurance and respect for privacy and dignity.
“People were content and happy and spoke positively about the friendliness and willingness of staff.” from the report
Good health support
Staff supported people's nutrition, healthcare and end-of-life needs. The home worked with several healthcare professionals when people needed additional help.
“Records demonstrated the involvement of speech and language therapy, psychiatric nurses, district nurses, dieticians and physiotherapists in people's care.” from the report
Individual communication and activities
Care plans explained how to support people with sight, hearing, language and other communication needs. People could choose from activities and decide how to spend their time.
“Communication care plans described people's individual needs and how staff should engage with people to ensure they provided responsive care.” from the report
Incomplete care records
needs fixingRecords about tube care, repositioning, food and drink, pressure-relieving mattresses and prescribed creams were not always complete. This made it difficult to confirm what care had been provided and whether some risks were being monitored properly.
“Records to support risk management in the home were not being consistently completed.” from the report
Delayed action on known issues
needs fixingThe provider's checks had identified some record-keeping problems, but the registered manager accepted that some actions should have been completed sooner. A new checking system was being introduced.
“The registered manager told us these would have been pulled through into the 'home improvement plan', but accepted that some actions should have been implemented sooner.” from the report
Environmental safety issue
seriousA door that should have been locked was not secure, and a dislodged drain cover created an infection control risk and a trip hazard. Immediate action was taken, but existing checks had not found the problem.
“The door was not locked and the cover to the drain in the room had been dislodged which presented an infection control risk and a trip hazard.” from the report
Management visibility
minorSome staff and relatives felt the management team was not visible enough around the home. Staff also said supervision meetings had not always taken place as regularly as they should.
“I'd like to see the manager around the home more” from the report
- 01How do you now check that repositioning, food and fluid, medicines, creams and tube-care records are completed accurately every day?
- 02What checks are in place for pressure-relieving mattresses, including recording the mattress type and settings?
- 03What has changed to make managers more visible and available to people, relatives and staff?
- 04How do you make sure new residents with complex health needs have an emergency care plan in place straight away?
- 05How are you reducing the use of agency staff and making sure temporary staff know each person's routines and preferences?
This was a comprehensive inspection covering all five key questions and checking improvements since the previous inspection. This explanation was written from the published report of 6 February 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 Alveston Leys Care Home
4 rated inspections over 8 years: the service has held its Good rating throughout.
- May 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2018Goodup from Requires improvementSafe: GoodWell-led: Requires improvement
- April 2017Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2015GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- December 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- October 2010
Registered with the Care Quality Commission on 1 October 2010.
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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