CQC report explained · a residential care home
What the CQC found at Leighswood
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Fire risks were not always safely managed. Inspectors also found weaknesses in medicine records and mask use, although people received their regular medicines as prescribed and staff met people's needs during the visit.
- Effective?
- Requires improvement
- The home did not always assess people's ability to make important decisions or follow the correct best-interest process. Oral health needs were also not individually recorded, although staff training, dietary support and access to healthcare were positive.
- Caring?
- Good
- People were treated with dignity, kindness and compassion. Staff comforted people when they were distressed and supported people's independence and choices.
- Responsive?
- Requires improvement
- People did not always have enough activities and could spend long periods without engagement. Care plans lacked detail for some people, especially those staying temporarily, although communication support and complaints processes were in place.
- Well-led?
- Requires improvement
- Quality checks had not found or dealt with several problems quickly enough. The provider had begun work to improve the culture and systems, but inspectors found the governance arrangements were not effective.
What inspectors found, September 2022
Rated Requires Improvement; inspectors found kind care, but safety, people's rights and management systems needed improvement.
This was an unannounced inspection on 22 and 23 June 2022. Inspectors spoke with 10 people, four relatives, staff and a visiting professional. They reviewed care plans, medicine records, staff files and management records.
People were treated with kindness and dignity. Staff knew people well, helped them with food and drinks, and supported them to access healthcare. However, fire risks, infection control and some medicine records were not always managed safely. People also spent long periods without activities.
The home did not always follow the legal rules about consent and restrictions. Its checks on quality and safety were not effective enough. The overall rating and the ratings for Safe, Effective, Responsive and Well-led were Requires Improvement. Caring was rated Good.
Kind and dignified care
Staff showed compassion and treated people respectfully. They spent time comforting people who were distressed.
“People were supported in a caring and dignified way by staff.” from the report
Food and drinks
People were supported to eat and drink enough. Staff understood specialist diets and paid particular attention to hydration during hot weather.
“People were supported to eat and drink enough and were encouraged to make healthy choices.” from the report
Staff knew people well
Staff could describe people's likes, dislikes and routines. People were supported to make choices about meals and their care.
“Staff knew people well and could describe people's likes and dislikes.” from the report
Healthcare support
People could access outside healthcare support when needed. A visiting professional said staff responded to advice and concerns.
“They are very engaging with us; anything we advise is done.” from the report
Fire, infection and medicine safety
seriousFire risks were not always controlled, including an unsuitable bedroom and unsafe rubbish in the smoking shelter. Medicine records for two as-required medicines were not available, and masks were not always worn correctly.
“Fire risks were not always safely managed.” from the report
Consent and restrictions
seriousThe home did not always record mental capacity assessments or follow the correct best-interest process. Some restrictions, including coded doors and a stair gate, had not been properly considered for everyone.
“The provider had failed to ensure people's rights were protected.” from the report
Too few activities
needs fixingPeople and relatives said there was not much to do, and inspectors saw people spending large amounts of time without engagement. An activities coordinator had been recruited to improve this.
“Whilst some activities took place at the home, people spent large amounts of time without any form of engagement.” from the report
Weak quality checks
seriousThe home's audits had not identified several problems, and actions were not always completed promptly. The home had also accommodated more people than it was registered for with CQC.
“The provider had failed to implement effective systems and processes to drive the quality and safety of the service.” from the report
- 01What has been done to make the bedroom, fire doors, fire plan and smoking shelter safe?
- 02How do you check that as-required medicines are available and that staff have the correct records?
- 03How do you record people's mental capacity, consent and best-interest decisions, including for CCTV and coded doors?
- 04What regular activities are now available, and how do you make sure people are not left without engagement?
- 05What did you do after the warning notice, and how do you now check that care plans and safety actions are completed?
This was an unannounced comprehensive inspection covering all five key questions, including infection prevention and control; it was the first inspection under the new provider. This explanation was written from the published report of 16 September 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.
What inspectors found, February 2022
Inspected but not rated; inspectors found good COVID-19 infection control arrangements, but this was not a full inspection of the home.
Inspectors visited on 9 February 2022. This was an announced, targeted inspection following COVID-19 outbreaks. It focused on infection prevention and control and asked about staffing pressures.
Inspectors found the home was clean and free from clutter. Staff used personal protective equipment correctly. There were systems for checking vaccinations and testing staff and residents.
The home supported safe visiting through testing, temperature checks and protective equipment. Staff also helped residents keep in touch with family and friends during visits or periods of isolation.
The service was inspected but not rated. Only the safe question was considered, and no rating was given. The report does not provide an overall rating of the home.
Clean environment
The home had regular cleaning arrangements and inspectors found it visibly clean and free from clutter.
“The home was visibly clean and free of clutter.” from the report
Use of PPE
Staff used protective equipment in line with government guidance, with PPE stations placed around the home.
“Staff wore Personal Protective Equipment (PPE) in line with current Government guidance and the registered manager had established PPE stations at key points throughout the home.” from the report
Testing and vaccination checks
The home had a process for monitoring vaccination status and testing for staff and residents.
“There was a clear process in place to monitor vaccination status and testing for staff and people at the service.” from the report
Contact with families
Staff helped residents keep in touch with family and friends through phone and video calls when visits were limited or people were isolating.
“Staff supported people to make phone and video calls to maintain contact with family and friends between visits and when people were isolating after testing positive for COVID-19.” from the report
Inspectors raised no specific concerns in this report.
- 01How are staffing pressures affecting residents' care and daily routines now?
- 02What checks are currently required for visitors, including testing, temperatures and PPE?
- 03How does the home prevent and manage infection outbreaks?
- 04How are staff and visiting professionals' vaccination or exemption status checked?
- 05How will residents keep in contact with family if visits are restricted or they need to isolate?
This was a targeted inspection of infection prevention and control and staffing pressures; the service was inspected but not rated and the other key questions were not assessed. This explanation was written from the published report of 22 February 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 Leighswood
9 rated inspections over 6 years: the service has held its Requires improvement rating throughout.
- September 2022Requires improvementcurrent ratingSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- February 2022Inspected but not ratedSafe: Inspected but not rated
- October 2020Requires improvementup from InadequateSafe: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- February 2020Inadequatedown from Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: InadequateWell-led: Inadequate
- March 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2018Requires improvementup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- February 2018Inadequatestayed InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- August 2017Inadequatestayed InadequateSafe: Inadequate
- April 2017Inadequatedown from Requires improvementSafe: InadequateEffective: InadequateCaring: InadequateResponsive: InadequateWell-led: Inadequate
- March 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2021
Registered with the Care Quality Commission on 1 June 2021.
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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