CQC report explained · a residential care home
What the CQC found at Letheringsett Hall
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, October 2017
Rated Good; inspectors found safe, kind and personalised care, with some improvements still needed in recruitment checks and activities.
This was an unannounced inspection on 1 September 2017. The inspectors spoke with 12 people living in the home, five relatives, staff and health professionals. They reviewed care and medicines records, recruitment files, training records, complaints and quality checks.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. People said they felt safe and were treated with respect. Inspectors found enough staff, safe medicines arrangements, suitable training and good support from health professionals.
The home had improved since the July 2016 inspection. Earlier problems with mental capacity decisions and governance had been addressed, so the home was no longer in breach of those regulations. A new manager was taking over, with the provider supporting the change.
There were still some shortcomings. One person started their induction before references and a DBS check had arrived. Some people wanted more individual activities, and a few audits did not clearly record which records had been checked.
People felt safe
People told inspectors they felt safe. Staff understood safeguarding and risks such as falls, poor nutrition and pressure areas were assessed with guidance in place.
“People were protected from avoidable harm and abuse by staff that had been trained in safeguarding.” from the report
Medicines were managed safely
Inspectors found checks on medicines when they arrived and before they were given. Storage and extra precautions were also handled appropriately.
“People's medicines were managed safely and administered as prescribed for them.” from the report
Respectful care
Staff protected people's dignity, asked permission and did not rush them. People and relatives were involved in planning care when appropriate.
“Staff were considerate of people's dignity and treated people with respect.” from the report
Improvement since the last inspection
The home had improved its mental capacity work and governance systems. The two previous breaches had been addressed.
“This September 2017 inspection found that the provider had addressed the majority of the concerns that had been raised from the July 2016 inspection.” from the report
Recruitment checks
needs fixingOne person started their induction before references and a DBS check had been received. The report says this was not safe practice, although the checks arrived the following week.
“However, one person had commenced their induction without references or a DBS check being received.” from the report
Activities were not fully personalised
needs fixingSome people said there was not much to do. The provider knew that activities needed to be better tailored to people's requests and had recruited someone with activities experience.
“The manager and provider were aware that they needed to improve and tailor the social support provided to better meet people's requests.” from the report
Some audits lacked detail
minorThe new quality monitoring system was a considerable improvement, but some audits did not say which care plans or staff records had been checked.
“A few audits required details of which aspects of the service had been sampled to be able to definitively support conclusions.” from the report
- 01How do you make sure references and DBS checks are received before any new staff member starts work?
- 02What one-to-one activities are now available for people who asked for more individual time?
- 03How do you record which care plans and staff records are included in each audit?
- 04Who is now registered as manager, and how was the handover completed after the previous manager left?
- 05How do you check that improvements to mental capacity assessments and DoLS applications continue in practice?
This was an unannounced inspection covering all five CQC areas; it also checked that breaches found in July 2016 had been addressed. This explanation was written from the published report of 17 October 2017 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, September 2016
Letheringsett Hall was rated Requires Improvement; inspectors found caring staff and good training, but concerns about consent, staffing, care records and oversight.
Inspectors visited on 18 and 21 July 2016. The first visit was unannounced. They spoke with people living in the home, relatives, staff and a health professional. They also checked care records, staff recruitment records, medicines and quality checks.
People generally said they felt safe, received their medicines and could access health professionals. Staff training was well organised. However, weekend staffing could be stretched, some staff comments were not respectful, and people were not routinely involved in reviewing their care plans.
The home did not properly assess people's ability to make specific decisions or record decisions made in their best interests. Inspectors also found weak checks on quality, medicines storage temperatures and legionella risks. The overall rating and all five question ratings were Requires Improvement, meaning the service was not consistently meeting the required standard.
Medicines administration
Staff were trained and had their competence checked before administering medicines. Inspectors saw medicines being given safely.
“All medicines were administered by staff who had received training and had their competencies checked.” from the report
Staff training
Training was organised and up to date. Staff received regular supervision and annual appraisals.
“The provider had robust systems in place for staff training and we saw that staff training was well organised and up to date.” from the report
Health care access
People could see health professionals when needed, including dentists, chiropodists and community nurses. Staff also supported people with hospital appointments.
“People's care records showed that there was access to a range of health professionals, including dentists, chiropodists and community nurses.” from the report
Privacy and dignity
People said staff respected their privacy. They gave examples of staff knocking before entering bedrooms.
“They respect your privacy. They always knock, all of them.” from the report
Mental capacity and consent
seriousThe home had not completed decision-specific mental capacity assessments or recorded best-interest decisions. This was a legal breach and could affect whether people's choices were properly respected.
“We did not find any decision specific mental capacity assessments in the care records that we looked at or references to specific decisions being made in people's best interests.” from the report
Weekend staffing
needs fixingCare staff sometimes had to prepare food or clean at weekends when other staff were unavailable. This could take them away from supporting people and lead to longer waits.
“On these days, and particularly on the days where there was no cleaner and no kitchen assistant people might be waiting longer for assistance” from the report
Respectful care
needs fixingAlthough many people praised staff, inspectors observed impatient or flippant comments and responses. This meant care was not consistently respectful.
“Some staff did not exhibit a caring or patient attitude towards people.” from the report
Care planning and activities
needs fixingCare records did not always describe people's emotional needs or provide clear, current guidance. There was also limited social stimulation, and some planned activities had not taken place.
“There was little recorded in care plans about emotional health conditions that people were living with, how this impacted upon their day to day lives and how staff needed to support people with this.” from the report
Quality and safety checks
seriousAudits did not identify problems found during the inspection. The home also lacked a suitable assessment of legionella risks. This was a legal breach.
“The provider had failed to ensure that an effective legionella risk assessment had been carried out.” from the report
- 01How do you now assess whether a resident can make each specific decision, and how do you record best-interest decisions?
- 02What staffing is in place at weekends when the cleaner or kitchen assistant is unavailable?
- 03How are care plans reviewed with residents and relatives, especially where someone has depression, anxiety or limited communication?
- 04How often are activities provided, and how do you record whether residents took part?
- 05What checks now cover medicines storage temperatures, legionella risks and the effectiveness of your audits?
This was an unannounced inspection over two days that assessed all five key questions and the overall quality of the home. This explanation was written from the published report of 20 September 2016 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 Letheringsett Hall
2 rated inspections over a year: the service has improved, from Requires improvement to Good.
- October 2017Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- June 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 10 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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13 live-in carers within about an hour of Norfolk
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £990 to £1,120 a week. 9 can care for a couple. 14 years' experience on average.
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