CQC report explained · a residential care home
What the CQC found at Leahyrst Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, January 2023
Leahyrst Care Home was rated Requires Improvement; inspectors found enough staff and generally safe care, but weak records and oversight remained.
This was an unannounced, focused inspection on 12 December 2022. Two inspectors spoke with six people, checked five care records, reviewed staff records and management records, and spoke with the manager and six staff members.
The home was rated Requires Improvement overall. Safe and Well-led were both rated Requires Improvement. The other three areas were not inspected during this visit, so their previous ratings were used for the overall rating.
Inspectors found enough staff, safe medicine storage and trained staff who understood safeguarding. Infection control arrangements were also found to be suitable. However, some care plans were out of date or contradictory, and important safety and management checks were not consistently recorded.
The home remained Requires Improvement, the same as at the previous inspection. The provider was still in breach of Regulation 17 because its systems did not reliably identify and correct problems.
Enough staff
Inspectors found enough staff to meet people's needs. Staff responded promptly to requests during the visit.
“There were enough staff to meet people's needs.” from the report
Safeguarding
People said they felt safe. Staff understood how to recognise and report possible abuse.
“Staff understood their safeguarding responsibilities.” from the report
Medicine training
Medicines were stored and disposed of suitably, and staff had training and competency checks for handling medicines.
“Staff received training in safe handling of medicines and had competency checks to make sure they gave medicines in a safe way.” from the report
Infection control
Inspectors were assured that the home had suitable arrangements for preventing and managing infections, including use of protective equipment.
“We were assured that the provider was using PPE effectively and safely.” from the report
People felt listened to
People said they were involved in decisions and could speak to management. Staff also described the management team as approachable.
“I feel listened to. They are easy to talk to and always have time for me.” from the report
Weak quality checks
seriousThe provider's monitoring systems did not reliably identify or fix problems. This was a continued breach of Regulation 17.
“The provider did not always have effective quality monitoring systems in place to ensure improvements are identified and sustained.” from the report
Incomplete safety records
needs fixingFire drills and several monthly safety checks had not been recorded. The manager said some checks had happened but had not been documented.
“The provider failed to record fire drills, as recommended by an external fire risk assessment.” from the report
Care plans did not always match needs
needs fixingSome care plans were contradictory and did not reflect changes shown in people's dependency assessments.
“We found some care plans were contradictory.” from the report
Food allergy knowledge
needs fixingKitchen staff could not describe or demonstrate which allergens might be present in meals. Inspectors recommended appropriate training.
“Kitchen staff were unable to describe and demonstrate the presence of any potential allergens in the meals provided.” from the report
Medicine room temperatures
needs fixingMedicine room temperatures were not always checked daily, which could affect assurance that medicines remained safe and effective.
“However, temperatures of the medicines room were not always monitored daily to make sure medicines would be safe and effective.” from the report
- 01What action has been taken to make sure fire drills and monthly safety checks are completed and recorded?
- 02How are care plans checked against people's current needs and risks?
- 03How are medicines room temperatures now monitored and reviewed?
- 04What food allergen training have kitchen staff completed, and how is their knowledge checked?
- 05What improvements were set out in the action plan sent to CQC after this inspection?
This was a focused inspection of Safe and Well-led only; the other ratings were carried over from the previous inspection. This explanation was written from the published report of 14 January 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 2021
Rated Requires Improvement; inspectors found important safety and record-keeping problems, although the home had improved and was no longer in special measures.
Inspectors visited on 17 December 2020 and gathered information from people, relatives, staff and professionals. They reviewed care, medicines, staff records, policies and other records. They also checked infection prevention and control arrangements because of COVID-19.
The home had improved since its previous inspection, when it was rated Inadequate and placed in special measures. People told inspectors they felt safe, medicines were generally managed safely, and relatives spoke positively about staff. The home had also improved nutrition support, activities, the environment and management support.
However, important risks were not always assessed or recorded properly. Inspectors also saw staff not following infection control measures, including PPE, hand hygiene and social distancing. Care was sometimes task-led rather than person-centred, and quality checks had not found all the problems. The home remained in breach of Regulations 12 and 17.
People felt safe
People and relatives told inspectors they felt safe. The home also had systems to record incidents and look for patterns.
“People told us the service was safe.” from the report
Medicines were generally safe
People received their medicines as prescribed, and staff had practical medicines training with annual checks of their competence.
“People received their medicines as prescribed.” from the report
Activities were becoming more personal
A new activities coordinator was planning activities around people's interests and offered one-to-one time to people who did not want group activities.
“The home had recently recruited an activities coordinator who was in the process of creating activity plans based on people's interests.” from the report
Staff felt supported
Staff spoke positively about the new manager and said they felt supported and valued. The manager was working to improve the culture of the home.
“Staff morale and feedback about management was positive.” from the report
Infection control was not followed
seriousInspectors saw staff not wearing PPE correctly, not following good hand hygiene, not keeping social distance during handover and not wearing surgical masks during personal care. The manager took immediate action, but this was a breach of Regulation 12.
“Staff were observed not to be wearing PPE and not following good hand hygiene practices when putting on/taking off PPE.” from the report
Some risks and records were unclear
seriousSome health and behavioural risks did not have suitable assessments or care guidance. Information in care plans, nutrition records and emergency evacuation records did not always match or remain up to date.
“Not all risks to people's safety and welfare were assessed appropriately.” from the report
Care was sometimes task-led
needs fixingSome staff approaches were not person-centred. Inspectors saw someone left for 20 minutes while being helped with a meal, and saw people directed away from where they wanted to sit.
“However, most staff were very task centred.” from the report
Some monitoring records were incomplete
needs fixingFluid charts were not always totalled daily, nutritional supplements were not always recorded, and there was no evidence that these charts had been audited. The manager said this would be addressed.
“Where people had been offered nutritional supplements, this wasn't recorded on the charts.” from the report
- 01What has changed since the inspection to make sure staff use PPE, follow hand hygiene and keep the required distance?
- 02How do you now check that risk assessments and care plans contain matching, up-to-date information?
- 03How are fluid, nutrition and supplement records checked and audited?
- 04What training and supervision do staff receive to help them provide person-centred care at mealtimes?
- 05What evidence can you show that the action plan has been completed and that improvements are being sustained?
This was a planned inspection following the previous Inadequate rating, covering all five key questions and including a specific check of infection prevention and control measures. This explanation was written from the published report of 5 February 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.
Every inspection of Leahyrst Care Home
6 rated inspections over 7 years: the service has improved, from Inadequate to Requires improvement.
- January 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- February 2021Requires improvementup from InadequateSafe: Requires improvementWell-led: Requires improvement
- April 2020Inadequatedown from GoodSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: InadequateWell-led: Inadequate
- July 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2016Requires improvementup from InadequateSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- February 2016InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: InadequateWell-led: Inadequate
- April 2014
Report published without a new overall rating.
- December 2013
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 20 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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