CQC report explained · a residential care home
What the CQC found at Lee Valley Care Services Limited
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, June 2023
Rated Requires Improvement; inspectors found unsafe risk and medicines management, with weak checks to identify problems.
This was an unannounced focused inspection on 11 and 16 May 2023. Inspectors spoke with 3 people and 5 staff. They reviewed care plans, risk assessments, staff records, medicines records and management documents.
The home had enough staff and people said they felt safe. Staff understood safeguarding, people were supported with food, drink and healthcare, and their choices were respected. Infection control arrangements were also found to be suitable.
However, some risk plans did not give staff enough detail about people’s health conditions or behaviours. Medicines were not always managed safely. For example, there were missing instructions for some medicines and errors in administration records.
The overall rating changed from Good to Requires Improvement. This means inspectors found important shortfalls and limited assurance about safety. The home was asked to produce an action plan, and progress will be monitored.
People felt safe
People told inspectors they felt safe and could get help from staff when needed.
“People told us they felt safe using the service.” from the report
Enough staff
Staffing records showed shifts were covered, and people said staff were available when they needed help.
“There were sufficient staff deployed to meet peoples' needs.” from the report
Respect for choices
Staff asked people how they wanted to be cared for and supported them without forcing them to do things.
“We observed staff asking people how they wanted to be cared for prior to supporting them.” from the report
Risk plans lacked detail
seriousSome plans did not explain clearly enough how staff should manage complex health needs, possible aggression or self-injury risks.
“However, plans to guide staff to manage identified risks did not always provide sufficient detail to minimise such risks.” from the report
Medicines records and guidance
seriousThere were no clear protocols for some as-required medicines, a recording discrepancy, and no suitable monitored pharmaceutical fridge. Inspectors were not assured that medicines were always given safely and as prescribed.
“Medicines were not always managed safely.” from the report
Fire safety issues
seriousThe fire risk assessment had not been reviewed since August 2021. Some fire doors did not close fully, and evacuation plans were not easy for staff to access.
“We found that the fire risk assessment provided had not been reviewed since 3 August 2021 and during the inspection we saw a number of fire doors not closing fully.” from the report
Staff mental health knowledge
needs fixingSome staff showed limited understanding of mental illnesses, triggers and signs of relapse. Inspectors recommended further guidance and training.
“However, during conversations with staff, we noted that staff showed little understanding and knowledge around various mental illnesses, their triggers and signs of mental health relapse.” from the report
Weak quality checks
seriousAudits did not find the problems inspectors identified in care plans, risk assessments and medicines management. This led to a breach of the governance regulation.
“The current quality assurance systems in place were not robust and effective to assess and monitor the quality of the service.” from the report
- 01What has been done to correct the medicines recording errors and provide protocols for as-required medicines?
- 02Can you show us the current risk plans for complex health needs, behaviours and self-injury, and explain how staff follow them?
- 03Has the fire risk assessment been reviewed, and are all fire doors and personal evacuation plans now safe and accessible?
- 04What mental health training have staff completed since the inspection, including training about triggers and relapse?
- 05How do managers now check that care plans, risk assessments and medicines records are accurate and problems are fixed promptly?
This was a focused inspection of Safe, Effective and Well-led, including infection control under Safe; Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 20 June 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 2021
Inspected but not rated; inspectors found good infection control, suitable staffing and clear records for as-required medicines.
This was an unannounced, targeted inspection on 15 March 2021. It focused on infection prevention and control, cleanliness, personal care, as-required medicines and staffing levels, following concerns raised by a local authority.
The home supported six people and could accommodate up to seven. Inspectors were assured that infection controls, personal hygiene, cleaning, testing, social distancing and protective equipment were being managed appropriately.
Inspectors also found clear instructions and recording for as-required medicines. Staff rotas showed suitable staffing during the day and overnight, including when some staff had to self-isolate.
The home and the Safe question were inspected but not rated. This means the report does not give a Good, Requires Improvement or Inadequate rating from this visit.
Infection control
Inspectors were assured that the home used protective equipment safely and had arrangements for preventing and managing outbreaks.
“We were assured that the provider was using PPE effectively and safely.” from the report
Cleanliness and hygiene
The home was being kept clean, and people were supported with their personal hygiene.
“The home was being kept clean and people were being supported to maintain their own personal hygiene.” from the report
Medicine records
For one person's infrequently used as-required medicine, staff had clear instructions and recorded why it was given.
“When this medicine was given staff recorded the reason why, the recorded reasons were in line with the protocol” from the report
Staffing cover
Inspectors found suitable numbers of staff on duty during the day and overnight. Staff cover continued when some workers had to self-isolate.
“Our examination of the staff rotas indicated a suitable number of staff on duty each day and overnight.” from the report
Contact and activities
The home supported social contact by phone and helped a person continue going for local walks when usual activities were unavailable.
“They were, however, able to have regular contact by phone with their relative at the home” from the report
Inspectors raised no specific concerns in this report.
- 01How are you currently checking that PPE, testing, cleaning and infection control arrangements remain effective?
- 02How do you decide when the person's as-required medicine should be given, and how do you check the records?
- 03How do you maintain staffing levels when staff are absent or need to self-isolate?
- 04How are visits from relatives arranged now, and how are families kept updated about a person's progress?
- 05What support is available for residents to take part in activities outside the home?
This was an unannounced targeted inspection of infection prevention and control and concerns about cleanliness, personal care, as-required medicines and staffing; it did not provide ratings for the other questions. This explanation was written from the published report of 16 April 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 Lee Valley Care Services Limited
5 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- June 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Lee Valley Care Services Limited →
- April 2021Inspected but not ratedSafe: Inspected but not rated
Read what inspectors found at Lee Valley Care Services Limited →
- June 2019Goodstayed GoodSafe: GoodEffective: GoodWell-led: Good
- December 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2016Requires improvementstayed Requires improvementSafe: Requires improvement
- January 2016Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- June 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 13 December 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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