CQC report explained · a nursing home
What the CQC found at Lezayre Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that risks were assessed and managed, infection controls were effective and staff were safely recruited. Medicines were generally managed safely, but one medicine was not given according to its protocol and some records needed clearer information.
- Effective?
- Requires improvement
- This key question was not inspected during this focused visit. Its previous rating was used to calculate the overall rating.
- Caring?
- Good
- This key question was not inspected during this focused visit. Its previous rating was used to calculate the overall rating.
- Responsive?
- Good
- This key question was not inspected during this focused visit. Its previous rating was used to calculate the overall rating.
- Well-led?
- Good
- Inspectors found systems for monitoring quality and safety, including audits, manager walk-arounds and action plans. People, relatives and staff gave positive feedback about the management and care.
What inspectors found, March 2023
Lezayre Nursing Home is rated Good; inspectors found safer care and better management, with some medicines records still needing clearer information.
This was an unannounced, focused inspection on 6 March 2023. Inspectors spoke with people living in the home, relatives and staff. They reviewed care records, medicines records, recruitment files and management checks.
The home was rated Good overall. Safe and Well-led were both rated Good. Inspectors found that risks were assessed, staff were safely recruited, infection controls were effective and medicines were generally managed safely.
There were some remaining issues. One medicine was not given in line with its protocol, some records needed more clarity and feedback about staffing levels was mixed. The manager acted on the medicines issue during the inspection.
The previous rating was Requires Improvement, published in July 2022. The earlier breaches about medicines and risk management had been resolved, and the recommended improvements to quality monitoring had been made. The other three areas were not inspected during this visit, so their previous ratings carried forward into the overall rating.
Risk management
People's risks had been assessed and care plans described their needs. Staff knew how to support people, including with repositioning, blood sugar checks and weight monitoring.
“Risks to people had been assessed and managed appropriately.” from the report
Clean and infection-aware
The home appeared clean and had infection prevention procedures, cleaning schedules and enough personal protective equipment.
“The home appeared to be clean and cleaning schedules were in place to help maintain this.” from the report
Responsive staffing
Inspectors saw people receiving help when needed and call bells being answered quickly. Recruitment checks had been completed.
“During the inspection, we observed people received support when they needed it and call bells were answered quickly.” from the report
Improved oversight
The home had introduced audits, daily walk-arounds and meetings to identify and follow up improvements. This addressed the recommendation from the previous inspection.
“A range of audits had been implemented, as well as daily manager walk-around and flash meetings, to help monitor the quality and safety of the service” from the report
Medicine protocol
needs fixingOne medicine was not given in line with its as-needed protocol. The manager reviewed this and updated the protocol during the inspection.
“However, records showed that one medicine was not administered in line with the guidance on the protocol.” from the report
Medicine records
needs fixingSome medicines records needed clearer information. Inspectors also said further written direction from the pharmacist was needed for medicines given covertly.
“Further written direction from the pharmacist to support the processes in place.” from the report
Mixed staffing feedback
minorMost people and relatives said staffing was sufficient, but some people and staff reported that staffing could be stretched, especially in the afternoons.
“Staff feedback was also mixed, with some staff stating afternoons could be busy when levels were reduced by one staff member.” from the report
- 01How do you now check that medicines given when needed are administered in line with their protocols?
- 02What additional pharmacist instructions are now in place for medicines given hidden in food or drink?
- 03How many staff are normally on duty in the afternoons, and what happens if staffing levels fall?
- 04Which ratings from the previous inspection apply to Effective, Caring and Responsive care?
- 05How are the new audits and action plans being used to keep checking safety and quality?
This was a focused inspection of Safe and Well-led; Effective, Caring and Responsive were not inspected and their previous ratings carried forward into the overall rating. This explanation was written from the published report of 22 March 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, July 2022
Rated Requires Improvement; inspectors found unsafe medicines management, incomplete care records and weak oversight, although people described kind care and enough staff.
Inspectors carried out an unannounced focused inspection on 26 May 2022. They spoke with people, relatives and staff, and checked care records, medicines, staff files and management records.
The home was not always safe. Risks were not always properly assessed or monitored. Some care plans were out of date, planned checks were missed, medicines were not always stored or recorded safely, and guidance for hidden medicines was unclear.
The service was also not always effective or well-led. Records about people's needs, nutrition, training and consent were incomplete or inconsistent. Audits did not identify all the problems or ensure that agreed actions were completed.
The overall rating was Requires Improvement, as were Safe, Effective and Well-led. Caring and Responsive were not inspected during this focused visit, so their previous ratings were used when calculating the overall rating. The home had also been rated Requires Improvement at the previous inspection.
Staffing and recruitment
The report found that staff were safely recruited and that people and relatives felt there were enough staff to meet people's needs.
“Staff were recruited safely. Records showed that relevant checks had been made to ensure staff were suitable to work in social care.” from the report
Kind staff
People, relatives and staff gave positive feedback about the home. Relatives described staff as caring and compassionate.
“The staff are caring and compassionate and nothing is too much trouble for them.” from the report
Food and healthcare
People said they had enough to eat and drink and enjoyed the meals. Staff contacted health professionals when people needed advice or treatment.
“People told us they had enough to eat and drink and enjoyed the meals available and relatives agreed.” from the report
Improved cleanliness
The home appeared generally clean, and people and relatives said cleanliness had improved recently. Staff had access to and used protective equipment appropriately.
“There has been a great improvement in cleanliness over the last few months,” from the report
Medicines
seriousMedicines were not always kept at the right temperature or recorded accurately. Staff also lacked clear instructions for giving medicines hidden in food or drink.
“The provider had failed to ensure medicines were managed safely. This was a continued breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Care plans and risk checks
seriousSome care plans did not match people's current needs. Records also showed that planned checks, including weight and blood sugar monitoring, were missed.
“Risks to people were not always fully assessed or mitigated.” from the report
Quality monitoring
needs fixingAudits did not identify all the problems found by inspectors, and some improvement actions had not been completed.
“They did not identify all the issues found during the inspection, such as those regarding medicines management, staff testing oversight, care planning or people's clinical needs not being monitored as planned.” from the report
Staff training records
needs fixingThe training matrix did not clearly show what training staff had completed. It showed that some practical fire and moving and handling training was outstanding.
“The training matrix showed that half of the staff had not completed practical fire training and nurses had not undertaken practical moving and handling training.” from the report
Consent records
needs fixingMental capacity assessments were not always completed before applications to restrict people's liberty. Records did not always prove that relatives had legal authority to give consent.
“Applications had been made to deprive people of their liberty. However, mental capacity assessments were not always completed as required prior to DoLS applications being submitted.” from the report
- 01How are you now checking medicine storage temperatures, including in the office?
- 02What written guidance do staff follow when medicines need to be given hidden in food or drink?
- 03How do you make sure care plans are updated when a person's mobility, diet or clinical needs change?
- 04Have all staff completed the practical fire and moving and handling training that was outstanding at the inspection?
- 05What changes have been made to audits so missed care, medicines problems and health monitoring are identified promptly?
This was an unannounced focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and their previous ratings were carried forward into the overall rating. This explanation was written from the published report of 6 July 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 Lezayre Nursing Home
7 rated inspections over 7 years: the service has held its Good rating throughout.
- March 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- July 2022Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- December 2021Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- December 2020Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- December 2018Goodup from Requires improvementSafe: GoodEffective: GoodWell-led: Good
- November 2017Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2014
Report published without a new overall rating.
- June 2014
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 21 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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