CQC report explained · a nursing home
What the CQC found at Leabrook House Nursing Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Good
- Inspectors found effective risk assessments, safeguarding systems, medicines management and infection control. Staffing sickness and agency use were affecting the time staff could spend with people.
- Effective?
- Requires improvement
- Health needs were generally well managed, but learning disability training was not yet in place and some people had waited for support with meals and drinks. Changes were made to the environment after the inspection.
- Caring?
- Requires improvement
- Some interactions were kind and friendly, but staffing pressures sometimes led to task-focused care without enough explanation or conversation. Cultural and religious needs were not always fully recorded.
- Responsive?
- Requires improvement
- People had activities and were supported with independence, but communication plans lacked detail and people sometimes spent long periods without meaningful interaction. The provider introduced Makaton flash cards and made changes to the dining area after the inspection.
- Well-led?
- Requires improvement
- The home had audits and worked well with external professionals, but audits had not found some gaps in care plans. There was no registered manager in post, and staff morale and communication with relatives needed improvement.
What inspectors found, May 2023
Rated Requires Improvement; inspectors found safe care and health support, but staffing pressures affected personal care, communication and people's daily experience.
This was an unannounced inspection on 28 and 30 March 2023. Inspectors spoke with people, relatives, staff and professionals, observed care, and checked care plans, medicines, recruitment records and management information.
The home was rated Good for Safe. Inspectors found improvements in medicines, risk management, infection control, diabetes care and support for people with PEG feeding or tracheostomies. They found no evidence that the concerns which prompted the inspection had put people at risk of harm.
The home was rated Requires Improvement overall and for Effective, Caring, Responsive and Well-led. Staffing pressures and low morale sometimes meant staff focused on tasks rather than interaction, while communication and cultural care plans were not always detailed enough. The home was no longer in breach of regulations found at the previous inspection.
Safe medicines and health care
Medicines were administered as prescribed, including medicines given through PEG tubes. Inspectors also found improved systems for diabetes care, nutritional feeds and complex nursing needs.
“Medication records correctly reflected the medications people had received and the remaining medications in stock at the service.” from the report
Improved risk management
Care plans and risk assessments gave staff detailed guidance about people's health needs. Fire safety, safeguarding and infection control arrangements were also found to be effective.
“Care plans and risk assessments were comprehensive to guide staff about people's health needs.” from the report
Good partnership working
The home worked with healthcare professionals and made referrals when needed. Inspectors found that professionals had positive views about communication and staff knowledge.
“Communication with my team and the nursing staff at Leabrook House is very good.” from the report
Activities and independence
People were offered daily activities and were supported to make choices and remain involved in their own care.
“An activity coordinator facilitated a program of daily activities for people.” from the report
Limited time for personal interaction
needs fixingPeople sometimes spent long periods without meaningful interaction because staff were focused on health tasks. Staffing sickness, agency use and low morale contributed to this.
“People often spent a long time without engagement, while staff attended to people's health needs.” from the report
Care was not always dignified
needs fixingSome staff interactions were task-focused and did not always explain what was happening. Inspectors also found inconsistent compassion and concerns about staff morale.
“We observed inconsistencies in the compassionate nature of interactions between staff and people.” from the report
Communication support plans lacked detail
needs fixingCommunication needs and preferences were not always fully assessed or recorded. Some staff lacked confidence supporting people who used non-verbal communication.
“People's communication needs weren't always fully assessed and documented.” from the report
Cultural and religious needs
needs fixingCare plans did not always explain the support needed for people's cultural and religious preferences. Inspectors heard that some personal care requirements had not been identified.
“Care plans didn't always give enough detail about the considerations staff should make about these important aspects of people's lives.” from the report
No registered manager
needs fixingThere was no registered manager in post during the inspection. The acting manager said they intended to apply to register.
“At the time of our inspection there was not a registered manager in post.” from the report
- 01How many permanent and agency staff are normally on duty for each shift, and how will you protect time for conversation and meaningful interaction?
- 02What training have staff completed in learning disabilities, autism and Makaton, and how will you support someone who communicates without speech?
- 03How will you record and deliver my relative's cultural, religious and personal care preferences?
- 04Who is currently responsible for managing the home, and what is the progress towards registering a manager with CQC?
- 05What changes have been made to the dining room and communal areas since the inspection, and how have these affected people's mealtimes?
This was an unannounced inspection covering all five CQC questions and infection prevention and control; inspectors also examined concerns about alleged abuse, neglect and cleanliness. This explanation was written from the published report of 31 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, July 2022
Leabrook House Nursing Home was rated Requires Improvement; people were generally comfortable with staff, but there were gaps in medicines records, consent checks and oversight.
This was an unannounced inspection on 29 March 2022. Inspectors spoke with three people, nine relatives and seven staff. They reviewed seven care records, three staff recruitment files and records about the home's management and quality checks.
The home was caring for 38 people and could support up to 41. People were described as relaxed and comfortable with staff. Staff understood people's health needs, had appropriate training and worked with health professionals. Infection control arrangements were also found to be effective.
However, inspectors found gaps and inconsistencies in diabetic care records. They also found that mental capacity assessments and best-interest decisions were not always recorded when restraint or restrictive practices were used. The home did not have a registered manager at the time.
The overall rating was Requires Improvement. Safe, Effective and Well-led were each rated Requires Improvement. These ratings had all remained the same since the previous inspection, published on 6 November 2019.
Staff knew people's needs
Staff understood people's health conditions and the support they needed. Inspectors found that people were comfortable and relaxed around care staff.
“People were comfortable, relaxed and happy around care staff and staff understood how to keep people safe.” from the report
Risk management
Risk assessments were in place, regularly reviewed and gave staff instructions for supporting people safely, including during seizures and emergencies.
“Risk assessments were regularly reviewed, and staff referred to these to ensure they supported people to reduce the risk of avoidable harm.” from the report
Training and health support
Staff had the skills and training needed for their roles. The home worked with GPs, dentists, opticians and other health professionals.
“People continued to be supported by a staff team who had the appropriate skills, knowledge and training to carry out their roles.” from the report
Infection control
Inspectors were assured about the home's arrangements for preventing and managing infection, including use of protective equipment and testing.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Diabetes and insulin records
seriousSome blood glucose records had unexplained gaps, and insulin instructions did not always match the medicines records. Inspectors said this could result in the wrong amount of insulin being given.
“The inconsistencies found in care records could result in staff, particularly agency staff who may be unfamiliar with people's routines, administering the wrong amount of insulin.” from the report
Consent and mental capacity
seriousThe home did not always complete decision-specific capacity assessments or record best-interest decisions, including when bedrails or other restrictive practices were used. This was a breach of Regulation 11.
“The provider had failed to ensure the principles of the MCA were followed as people did not always have their capacity assessed for specific decisions and best interests' decisions recorded as required.” from the report
Weak quality checks
seriousThe provider's audits had not identified several problems, including incomplete diabetes records, unmonitored feed storage temperatures and missing consent records. This was a continued breach of Regulation 17.
“Systems and processes to assess and monitor the quality and safety of the service were not robust.” from the report
Incomplete follow-up
needs fixingOne planned catheter change had not been completed, and a recommendation from a healthcare review six months earlier had not been followed up.
“The provider had also failed to identify a key recommendation from one person's healthcare review, six months ago, had not been followed up by staff or management.” from the report
Staff recruitment records
needs fixingChecks were carried out, including criminal record checks, but the files did not always contain enough information to show that all required pre-employment checks had taken place.
“However, staff recruitment records did not always contain enough information to demonstrate all required pre-employment checks had taken place” from the report
- 01How have you corrected the diabetic care charts and checked that insulin authorisations match the medicines records?
- 02How do you now make sure blood glucose readings are recorded every time and that normal ranges are clear?
- 03How are you completing and recording mental capacity assessments and best-interest decisions before using bedrails or other restrictive practices?
- 04Has a registered manager now been appointed, and what evidence can you show that the Regulation 17 governance breach has been addressed?
- 05Have the catheter change, healthcare recommendation, PEG feed temperature checks and clearer bedroom signage all been completed?
This was an unannounced inspection examining Safe, Effective and Well-led; the report does not give ratings for Caring or Responsive. This explanation was written from the published report of 1 July 2022 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 Leabrook House Nursing Home
5 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- May 2023Requires improvementcurrent ratingstayed Requires improvementSafe: GoodEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- July 2022Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- November 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- June 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2015GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2013
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 14 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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