CQC report explained · a residential care home
What the CQC found at Lever Edge Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People felt safe, staffing levels were based on people's needs, and medicines, safeguarding, accidents and risks were managed safely. Inspectors noted that some staff did not wear PPE consistently during a night visit, and fire drills did not involve evacuating people from specific areas.
- Effective?
- Good
- Staff had suitable training, supervision and appraisals. People's health, nutrition, communication and legal decision-making needs were supported, although food and fluid records sometimes needed more detail.
- Caring?
- Good
- People and relatives spoke positively about staff. Inspectors observed kind and respectful care, privacy being protected and people being encouraged to remain as independent as possible.
- Responsive?
- Good
- Care plans included people's histories, likes, dislikes and communication needs. The home provided activities twice a day, seven days a week, and supported contact with relatives during COVID-19 restrictions.
- Well-led?
- Good
- The home used audits, feedback and an improvement plan to monitor and improve care. People, relatives and staff were asked for their views, and staff described the management team as supportive.
What inspectors found, November 2021
Lever Edge Care Home was rated Good; inspectors found safe, kind and well-managed care, with a few records and infection-control practices needing attention.
Inspectors visited on 12 and 20 October 2021. They spoke with people living in the home, relatives, staff and visiting professionals. They reviewed care records, medicines records, staffing information, incident records and quality checks.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. People said they felt safe and well cared for. Inspectors found enough staff, safe medicines practice, suitable training, kind interactions and care plans that reflected people's needs and preferences.
The inspection was prompted by concerns about staffing, staff support, falls and incidents, medicines, DoLS and care quality. Inspectors found no evidence that people were at risk of harm from these concerns. They did note that some fire drills did not include evacuating people from specific areas, some staff were not consistently wearing PPE during a night visit, and food and fluid records sometimes lacked detail.
Safe staffing and medicines
Inspectors found enough staff to meet people's needs. Medicines were given safely by trained and assessed staff.
“People received their medicines safely by staff who were trained and assessed as competent.” from the report
Learning from incidents
Falls, accidents and incidents were recorded and reviewed for patterns. The home used action plans and professional referrals to reduce the chance of problems happening again.
“Accidents, incidents and falls had been recorded consistently, with analysis completed to look for trends to help prevent a reoccurrence.” from the report
Kind and respectful care
People looked comfortable and well cared for. Inspectors saw staff greet people warmly, protect privacy and support independence.
“People were treated with dignity and respect and encouraged to do as much for themselves as they could.” from the report
Personalised support
Care records included people's backgrounds, preferences and communication needs. Relatives and people were involved in care planning.
“Care files contained a range of person-centred information.” from the report
Activities and relationships
The home offered regular activities and helped people keep in touch with relatives during COVID-19 restrictions.
“The home provided activities twice a day, seven days per week; these took place on specific units, rather than across the home as a whole.” from the report
Quality oversight
Managers used audits, feedback and a weekly improvement plan to identify actions and monitor progress.
“A home improvement plan was used to capture any actions or issues identified via auditing, monitoring or feedback from people and staff.” from the report
Fire evacuation practice
needs fixingFire drills were carried out, but they did not include evacuating people from specific areas as would happen in an emergency. The manager agreed to change this.
“Fire drills were undertaken regularly, although we noted these did not involve people being evacuated from specific areas, as they would be in an emergency.” from the report
PPE was not always worn consistently
minorDuring the night visit, some staff were not wearing PPE consistently in line with guidance. This was addressed at the time.
“During our night visit, we found some staff not wearing PPE consistently as per guidelines, however, this was addressed at the time by the deputy manager.” from the report
Food and fluid records
needs fixingRecords were completed consistently, but sometimes did not say exactly what people had eaten or how it had been prepared or served.
“However, whilst done consistently, greater detail was required at times, to ensure entries specified exactly what people had eaten and how this had been prepared or served.” from the report
- 01What changes have been made to fire drills so they include evacuating people from the areas where they live?
- 02How do you check that staff wear PPE consistently, including during night shifts?
- 03What extra checks are now in place to make sure food and fluid records describe exactly what each person ate and how it was prepared or served?
- 04How are activities chosen for each unit, and how do you make sure they suit my relative's interests and communication needs?
- 05How will you tell families about progress on the actions in the home improvement plan?
This inspection covered all five CQC questions and infection prevention and control, and examined concerns about staffing, staff support, falls and incidents, medicines, DoLS and care quality. This explanation was written from the published report of 25 November 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.
What inspectors found, November 2020
Rated Requires Improvement; inspectors found safe, kind and well-managed care, but this was only a focused inspection.
Inspectors visited the home on 8 October 2020 and carried out further inspection activity until 22 October. They spoke with people, relatives and staff, observed care, and checked care, medicines, staffing and management records.
They found that people were safe, treated with kindness and supported by a well-organised management team. Medicines, infection control, safeguarding, staffing and risk assessments were described as effective.
The overall rating remained Requires Improvement. Safe, Caring and Well-led were each rated Good. Effective and Responsive were not inspected during this visit, so their earlier ratings were used in the overall result.
Safe care and medicines
Risks were assessed and medicines were administered safely. The home also had suitable infection control measures and supplies of protective equipment.
“Medication was administered safely. Staff had a good understanding around the timely administration of medication.” from the report
Kind and respectful staff
People and relatives spoke positively about the staff. Inspectors saw care that respected privacy, dignity, choice and independence.
“Staff cared for people in a warm and friendly manner.” from the report
Strong management
The management team supported staff and used audits to identify and complete improvements. Staff training was up to date and roles were clear.
“Auditing and analysis systems were in place and these were used as a tool to identify areas where improvements could be made and risks managed.” from the report
Inspectors raised no specific concerns in this report.
- 01What were the previous ratings for Effective and Responsive, and what improvements have been made in those areas since then?
- 02How do you check that people's care plans and risk assessments remain up to date?
- 03How do you monitor staffing levels at the times when accidents and incidents have happened more often?
- 04How will you keep relatives informed about activities, visits and infection control measures?
- 05How do you check that medicines are given on time and that refused medicines are recorded correctly?
This was a focused inspection of Safe, Caring and Well-led; Effective and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 27 November 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 Lever Edge Care Home
6 rated inspections over 5 years: the service has improved, from Inadequate to Good.
- November 2021Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2020Requires improvementstayed Requires improvementSafe: GoodCaring: GoodWell-led: Good
- June 2019Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- November 2018Inadequatedown from GoodSafe: InadequateEffective: Requires improvementCaring: InadequateResponsive: Requires improvementWell-led: Inadequate
- September 2016Goodup from InadequateSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2016InadequateSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- November 2013
Report published without a new overall rating.
- February 2013
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 7 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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