CQC report explained · a residential care home
What the CQC found at St Leonards Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Some people's risks, including falls, pressure damage, diabetes and seizures, were not properly recorded or managed. Recruitment checks were incomplete, although medicines were given as prescribed, safeguarding systems were in place and required staffing levels were provided.
- Effective?
- Requires improvement
- The home did not always follow the Mental Capacity Act when making decisions about medicines, personal care, vaccinations and hospital treatment. Staff competency checks and some training records were also incomplete.
- Caring?
- Good
- This question was not assessed during this focused inspection, so no new rating was given.
- Responsive?
- Good
- This question was not assessed during this focused inspection, so no new rating was given.
- Well-led?
- Requires improvement
- Audits identified problems, but action was not always taken quickly enough. Records were not consistently accurate or up to date, although the manager was visible, approachable and committed to improving the service.
What inspectors found, May 2023
St Leonards Care Home was rated Requires Improvement; inspectors found kind care and good activities, but concerns about risk management, staff checks, consent and records.
This was an unannounced focused inspection on 24 and 26 April 2023. Inspectors spoke with people, staff and relatives, observed care, checked the home and reviewed care plans, medicine records, recruitment files and management records.
The home was not always safe or effective. Risks were not consistently identified or managed, some staff checks and competency assessments were incomplete, and records were sometimes missing, out of date or contradictory. The home also did not always follow the legal process for making decisions for people who could not make those decisions themselves.
There were positive findings. People and relatives said they were happy with the care. Staff were described as kind and available, people had access to varied activities, and health and nutritional needs were generally met. The manager was involved and accepted the problems identified.
The overall rating changed from Good at the last inspection, published in 2017, to Requires Improvement. This inspection only assessed Safe, Effective and Well-led. The other questions were not inspected and did not receive new ratings.
Kind and available staff
People and relatives said staff were kind, supportive and available when needed. Inspectors saw call bells answered promptly and care did not appear rushed.
“People were supported by a consistent staff team.” from the report
Activities
The home offered regular activities in the home and in the community. People were involved in choosing what they wanted to do.
“They had a varied, community based and in-house person-centred activity programme with people involved in making choices on what activities they wanted.” from the report
Health and nutrition
People were assessed before moving in, and the home worked with health professionals. Inspectors found that nutritional and hydration needs were being met.
“People were assessed prior to moving into the service and their health and nutritional needs were met.” from the report
Positive management relationships
The manager was regularly present and had positive relationships with people, relatives and staff. They accepted the shortfalls and said they were committed to improvement.
“The registered manager was actively involved in the running of the service.” from the report
Risks were not always managed
seriousSome care plans did not explain how to manage important risks, including falls, diabetes, pressure damage and seizures. Some records conflicted with each other, and required night checks had gaps.
“Risks to people were not consistently identified, mitigated, and reviewed.” from the report
Recruitment and staff skills
seriousSome staff files did not contain the required references. Staff carrying out medicines, personal care or moving and handling did not always have current competency checks.
“Staff were not suitably recruited and did not have their competencies assessed for the tasks they were involved in, including administration of medicine.” from the report
Consent decisions
seriousThe home did not record decision-specific capacity assessments and best-interest decisions where needed. This affected decisions about medicines, personal care, vaccinations and hospital treatment.
“People's care plans showed decision specific mental capacity and best interest decisions were not in place for everyone who required them” from the report
Weak records and audits
seriousAudits found problems, but action was not always timely. Records, staff competency information, agency staff details and some servicing records were not consistently maintained.
“Good governance was not established to ensure the service was suitably monitored and that records were accurate.” from the report
Pressure on some shifts
needs fixingAlthough the home provided the staffing levels it considered necessary, some staff said shifts could be challenging because of increased care and administration work.
“Not enough staff on day or night shifts. The shifts can be challenging as a number of residents require a lot of help and support from 2 staff members,” from the report
- 01Have all care plans and risk assessments been updated for falls, diabetes, pressure damage, seizures and changes in mobility?
- 02Have all staff who give medicines or provide personal care and moving and handling support completed and passed their competency assessments?
- 03How have you completed the required references and other recruitment checks for permanent and agency staff?
- 04How do you record mental capacity assessments and best-interest decisions for medicines, personal care, vaccinations and hospital treatment?
- 05What action has been taken to make audits, care records, agency staff records and servicing records accurate and up to date?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and did not receive new ratings. This explanation was written from the published report of 31 May 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, February 2021
Inspected but not rated; inspectors were assured about infection control during a COVID-19 outbreak.
This was a targeted, announced inspection on 3 February 2021. It looked only at infection prevention and control during the coronavirus pandemic.
Inspectors were assured that the home used PPE safely, followed shielding and social distancing rules, carried out testing, and kept its infection control policy up to date.
The home had suspended visits for most relatives at the time, except at the end of life. It offered technology as another way for people to stay in contact.
The inspection did not give an overall quality rating. Safe was recorded as inspected but not rated, and the other areas were not assessed during this visit.
Infection control
Inspectors were assured that the home had measures to prevent and manage infection, including safe PPE use and up-to-date policies.
“We were assured that the provider was using PPE effectively and safely.” from the report
Outbreak response
The provider and staff had taken action during a COVID-19 outbreak and recorded what they were doing to support people and staff.
“The provider and staff had taken immediate action to manage an outbreak situation and they recorded the ongoing actions taken to support people and staff through an outbreak of COVID-19.” from the report
Keeping in touch
Although most visits were suspended at the time, the home used technology to help people stay in contact with relatives.
“Alternative ways, including the use of technology, had supported people's ability to remain in contact with their relatives.” from the report
Health monitoring
People were monitored for COVID-19 and other infection symptoms. Healthcare professionals continued to provide clinical support when needed.
“People's health and wellbeing was monitored. People were observed for symptoms of COVID-19 and other potential infections.” from the report
Inspectors raised no specific concerns in this report.
- 01What are the current visiting arrangements, and what happens if there is another infection outbreak?
- 02Who is currently responsible for managing the home when the registered manager is absent?
- 03How are residents and staff tested for COVID-19 and other infections now?
- 04How do you support residents to keep in contact with relatives if visits are restricted?
- 05How do you support residents to self-isolate while preserving their wellbeing?
This was a targeted inspection of infection prevention and control under Safe; it did not assess the other four key questions or give an overall rating. This explanation was written from the published report of 24 February 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.
Every inspection of St Leonards Care Home
3 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- May 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2021Inspected but not ratedSafe: Inspected but not rated
- November 2017Goodup from Requires improvementSafe: GoodEffective: GoodWell-led: Good
- October 2016Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2014
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 16 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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