CQC report explained · a residential care home
What the CQC found at 48 Leonard Road
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, November 2021
Homewards Limited - 48 Leonard Road is rated Good; inspectors found kind, person-centred care and major improvements, with a few records and safety points needing attention.
Inspectors visited on 25 August and 2 September 2021. They spoke with a person using the home, staff, the manager, a relative and others. They observed care and checked medicines, care plans, staff files, incident records and quality checks.
The home supported three people, although it could accommodate up to four. Inspectors found enough trained staff, safer premises, more detailed risk assessments and improved recruitment checks. People were supported to make choices, build independence, take part in activities and keep contact with family.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. The service had previously been rated Inadequate and placed in Special Measures. Inspectors found the earlier breaches had been addressed, so the home was no longer in Special Measures.
Improved safety
The provider had fixed health and safety problems found at the previous inspection. Risk assessments were more detailed and regular checks were in place.
“The health and safety issues identified at the last inspection were found to have been fixed.” from the report
Kind and respectful care
Staff knew people well and supported their privacy, dignity, choices and family relationships.
“People or their families told us that they received kind and compassionate care.” from the report
Support for independence
People were encouraged to make choices and take part in everyday tasks and activities at their own pace.
“The model of care and setting maximised people's choice, control and independence.” from the report
Personalised support
Care plans reflected people's communication, sensory, health and emotional needs. Staff worked with other professionals when extra help was needed.
“Care and support plans were holistic and reflected people's needs and aspirations.” from the report
Stronger leadership
The provider had introduced quality checks, staff meetings and ways for people and relatives to give feedback.
“The provider had made improvements since the last inspection and now had a system in place to check the quality of the service.” from the report
Fire risk assessment
needs fixingA fire risk assessment was missing for a person using a paraffin-based skin cream. The provider corrected this on the inspection day, but CQC made a recommendation about the associated risks.
“There was a missing fire risk assessment for a person prescribed a paraffin-based skin cream.” from the report
Medicines record
minorOne newly prescribed as-needed medicine was not yet listed on the medicines administration record. The service corrected this immediately, and records showed the medicine had not been needed.
“We found one newly prescribed "as required" medicine had not been included on the person's medicines administration record (MAR).” from the report
Care plan repetition
needs fixingCare plans had improved but included a lot of repeated information. Inspectors said this could make it harder for new staff to find relevant guidance.
“However, we found there was lot of repetition which made it difficult for new staff to easily find relevant information.” from the report
PPE practice
minorInspectors saw one example of an incorrect mask being worn. The manager addressed this immediately.
“We saw one example where an incorrect mask was worn.” from the report
- 01How do you make sure fire risk assessments are updated when someone uses paraffin-based skin products?
- 02How do you check that newly prescribed medicines are added to medicines administration records before they are needed?
- 03What are you doing to reduce repetition in care plans and help new staff find key information quickly?
- 04How do you check that staff use the correct PPE?
- 05What improvements have been made since the previous Inadequate inspection, and how are they being maintained?
This was a comprehensive follow-up inspection covering all five key questions, with an additional focus on applying the Right support, right care, right culture principles and infection prevention and control. This explanation was written from the published report of 27 November 2021 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, September 2020
Inspected but not rated; the previous rating was Inadequate, while inspectors found improvements but incomplete incident records.
This was a targeted inspection on 15 July 2020. It followed concerns about activities, accidents and incidents, risk management, safeguarding, staffing, and food and nutrition. One inspector visited, reviewed records, spoke with one person, managers, relatives and staff, and checked recruitment files and policies.
Inspectors found enough staff, suitable risk assessments, adequate infection control supplies, varied food and a range of activities. Relatives said people were safe, and staff understood how to report suspected abuse. The provider updated its safeguarding policy after the inspection.
There were still gaps in record keeping. Incident forms were not always completed when behaviour charts were used or when medicine was given as needed for behaviour. One staff member was also seen wearing a mask incorrectly.
The service was inspected but not rated. This means the inspection did not review every part of each area. The previous ratings remain in place: Safe and Well-led were Inadequate, while Effective and Responsive were Good.
Staffing improved
Inspectors found there were enough staff to meet people's needs. Relatives and staff also said staffing was adequate.
“At this inspection we found this had improved and there were enough staff.” from the report
Risk planning
People had assessments covering risks such as medicines, falls, eating and drinking, behaviour and infection control.
“People had risk assessments to reduce the risks of harm they may face.” from the report
Food and drink
Inspectors found that people's nutrition and hydration needs were being met. The home had fresh food and healthy choices.
“The menu was varied and nutritious and included healthy eating options.” from the report
Activities and family links
People were offered different activities, including home-based activities during the pandemic. Records showed support to keep in touch with family.
“People's activity planners showed a variety of activities were offered which included attending, prior to the pandemic, classes in pottery, art and music.” from the report
Incomplete incident records
needs fixingIncident forms were not always completed after behaviour charts or when as-needed behaviour medicine was given. Managers said staff had recently been trained and audits would check whether this improved.
“Incident forms were not always completed for one person following completion of behaviour charts or when 'as needed' medicine for behaviour management was administered.” from the report
Mask worn incorrectly
minorA staff member was seen wearing a mask under their chin. Managers said they would remind staff how to wear protective equipment correctly.
“However, during our visit, we observed a staff member wearing a mask underneath their chin which meant the mask could be contaminated.” from the report
- 01How do you now check that incident forms are completed after behaviour charts or as-needed behaviour medicine?
- 02What evidence can you show that the recent record-keeping training has improved practice?
- 03How do you monitor staff use of masks and other protective equipment?
- 04What action has been taken since the previous Inadequate ratings for Safe and Well-led?
- 05How are activities and family contact planned for each person, including during restrictions?
This was a targeted inspection of specific concerns about Safe, Effective, Responsive and Well-led; it did not review the full key questions, so the previous ratings carried over. This explanation was written from the published report of 19 September 2020 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 48 Leonard Road
4 rated inspections over 5 years: the service has held its Good rating throughout.
- November 2021Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2020Inspected but not ratedSafe: Inspected but not ratedEffective: Inspected but not ratedResponsive: Inspected but not ratedWell-led: Inspected but not rated
- October 2019Inadequatedown from GoodSafe: InadequateWell-led: Inadequate
- August 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2015
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 11 January 2011.
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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