CQC report explained · a residential care home
What the CQC found at Leighton House Retirement Home 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, March 2022
Leighton House Retirement Home Limited was inspected but not rated; inspectors found mostly effective infection controls, with visitor checks and some mask use needing improvement.
This was a targeted inspection on 2 February 2022. Inspectors looked at infection prevention and control, and asked about staffing pressures linked to COVID-19. The visit was announced one day in advance.
The home had regular COVID-19 testing, vaccination arrangements for staff, effective cleaning and systems to support visits. Inspectors were assured about testing, admissions, social distancing, hygiene and managing outbreaks.
Inspectors were only somewhat assured about visitor checks, the safe use of PPE and whether the infection control policy was up to date. During the inspection, the home added visitor measures and updated its policy.
The service was inspected but not rated. This was not a full inspection of all five areas of care, so the report does not provide an overall quality rating.
Testing and vaccination
People and staff were tested regularly, and staff had been vaccinated to reduce infection risks.
“People and staff were tested regularly for COVID-19, in line with government guidance.” from the report
Clean environment
The home was clean and well maintained, with cleaning schedules and audits in place.
“The environment was clean, well maintained and hygienic.” from the report
Outbreak planning
The home had risk assessments, policies and contact with local infection control teams to manage COVID-19 risks.
“The registered manager had regular contact with the local authority and infection control teams.” from the report
Visitor checks
needs fixingThe process for checking visitors was not robust enough to prevent infection being brought into the home. The home added measures during the inspection.
“Processes when visitors entered the home needed to be more robust.” from the report
Mask use
needs fixingOne staff member was seen wearing a mask incorrectly. Inspectors were therefore only somewhat assured that PPE was being used safely.
“However, we did observe one staff member who was not wearing their mask appropriately.” from the report
Infection control policy
needs fixingInspectors were only somewhat assured that the infection control policy was up to date. The home updated it during the inspection.
“We were somewhat assured that the provider's infection prevention and control policy was up to date.” from the report
- 01What additional checks are now carried out when visitors enter the home?
- 02How do you make sure all staff wear PPE correctly at all times?
- 03When was the infection prevention and control policy last reviewed and updated?
- 04What actions were taken after inspectors found the visitor process was not robust enough?
- 05How are COVID-19 testing and vaccination arrangements currently managed?
This was a targeted inspection of infection prevention and control and COVID-19-related staffing pressures; it did not provide ratings for the other areas of care. This explanation was written from the published report of 4 March 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, January 2020
Leighton House Retirement Home Limited is rated Good; inspectors found safe, kind and person-centred care, with staffing cover during sickness worth checking.
This was an unannounced inspection on 8 January 2020. One inspector spoke with people living there, relatives and staff, reviewed care and staff records, observed care, and toured the building and gardens.
All five areas were rated Good: safe, effective, caring, responsive and well-led. Inspectors found suitable risk checks, safe medicines procedures, trained staff, nutritious food, personalised care plans, activities and approachable management.
The overall rating was unchanged from the previous inspection in July 2017. The report says there were no complaints and that the service would continue to be monitored under the usual reinspection programme.
Safe medicines
Inspectors found that medicines were administered safely, records were complete and instructions for medicines given only when needed were clear.
“We checked the medicines records and found they were completed correctly and 'as required' medicines gave staff clear instructions to administer them safely.” from the report
Personalised care
Care plans recorded people's histories, preferences, interests and routines. They were reviewed and updated when people's needs changed.
“Plans of care were person centred and contained details of people's likes and dislikes to meet their individual needs.” from the report
Kind relationships
Inspectors saw positive relationships between staff and people, with a friendly atmosphere and staff who knew people well.
“Staff had a good relationship with people who used the service and there was a good atmosphere with laughter and good-natured banter.” from the report
Food and healthcare
People had meal choices, fresh fruit and drinks, with specialist advice sought when needed. Records showed support with hospital, GP, dental, optical and podiatry appointments.
“People were given a choice of meal at every serving. Drinks and fresh fruit were readily available.” from the report
Open management
People, relatives and staff said management was available and approachable. The home used audits, meetings and outside organisations to support quality improvement.
“The registered manager attended meetings with organisations in the health and social care community to discuss best practice and help drive improvement.” from the report
Staff cover during sickness
minorStaff said there were enough staff to meet people's needs, but shortages happened on rare occasions because of sickness. Ask what backup arrangements are used at these times.
“People told us they were attended to quickly when they needed assistance and staff confirmed there were enough staff to meet people's needs, except on rare occasions due to sickness.” from the report
- 01What backup staffing arrangements are used when staff are off sick?
- 02How will you involve my relative and family in reviewing and updating their care plan?
- 03How do you make sure activities reflect each person's interests, culture and religious needs?
- 04How do you check that medicines, including medicines given only when needed, are administered and recorded safely?
- 05If my relative needs end of life care, what support would you provide and which external professionals would be involved?
This was an unannounced planned inspection covering all five CQC questions, and all five ratings remained Good from the previous inspection. This explanation was written from the published report of 31 January 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 Leighton House Retirement Home Limited
3 rated inspections over 5 years: the service has held its Good rating throughout.
- March 2022Inspected but not ratedcurrent ratingSafe: Inspected but not rated
Read what inspectors found at Leighton House Retirement Home Limited →
- January 2020Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Leighton House Retirement Home Limited →
- July 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2014GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- August 2012
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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