CQC report explained · a residential care home
What the CQC found at St Leonards Court
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Nine records of harm had not been reported to the local safeguarding team, and one person was not supervised as required by their care plan. Infection control practice was also inconsistent, although staffing, recruitment, risk assessments and medicines were generally satisfactory.
- Effective?
- Good
- This question was not inspected during this focused visit. The previous rating was carried forward.
- Caring?
- Good
- This question was not inspected during this focused visit. The previous rating was carried forward.
- Responsive?
- Good
- This question was not inspected during this focused visit. The previous rating was carried forward.
- Well-led?
- Requires improvement
- Managers did not always oversee incidents properly, and there were concerns about statutory notifications to the CQC. The report also describes a new manager, audits, meetings and an action plan aimed at improving the home.
What inspectors found, December 2021
Rated Requires Improvement; inspectors found risks from missed safeguarding reports, poor incident oversight and inconsistent infection control.
This was an unannounced focused inspection on 2 and 12 November 2021. Inspectors looked only at Safe and Well-led because concerns had been raised about staffing, cleanliness and personal care. They spoke with people and staff, observed care, and checked care, medicines, recruitment and management records.
Inspectors found that nine records of harm between people had not been reported to the local safeguarding team. Some incidents had not been properly investigated, and one person was left with others without the staff supervision required by their care plan. The report says incidents recurred and people were harmed.
Staffing, recruitment, medicines and risk assessments were generally found to be appropriate. However, staff did not always use protective equipment correctly or clean equipment and change gloves when supporting nail care. Management oversight and reporting to the CQC were also not reliable.
The overall rating fell from Good at the previous inspection, published in August 2018, to Requires Improvement. The home was in breach of Regulation 13. The manager took immediate steps during and after the inspection, and the CQC requested an action plan and said it would monitor progress.
Staffing and recruitment
Inspectors found enough staff to support people safely and said recruitment checks were completed before staff started.
“There were enough staff on duty to support people safely and we saw they had the skills to meet people's needs.” from the report
Medicines
Medicines were given appropriately, with trained staff, competency checks and arrangements for medicines prescribed when needed.
“Medicines were administered by trained staff who also underwent regular competency checks.” from the report
Risk assessments
People had risk assessments and staff could explain the risks, triggers and support needed for different behaviours and health conditions.
“Staff were able to explain how these behaviours may present, triggers to be aware of, and how to support the individual.” from the report
Manager engagement
People and staff spoke positively about the new manager. The manager engaged with people and families and used meetings and surveys to identify improvements.
“The manager promoted a culture of person-centred care by engaging with everyone using the service and their family members.” from the report
Safeguarding reports
seriousNine records of harm between people had not been reported to the local safeguarding team. This meant opportunities to prevent further harm may have been missed.
“We saw nine records of person on person harm that had not been reported to the local safeguarding team.” from the report
Supervision and repeat incidents
seriousA person was left with others without the staff supervision required by their care plan. Incident investigations were not always completed, and the report says people were harmed.
“This placed people at risk from harm.” from the report
Infection control
needs fixingStaff sometimes pulled masks down and did not always clean equipment or change gloves during nail care. The manager acted immediately after inspectors raised this.
“Staff did not always ensure that they cleaned equipment or changed their gloves when supporting people with cutting their nails.” from the report
Management oversight
needs fixingIncident checks had been delegated but were not always overseen properly. The provider's systems had not identified the problems, and some CQC notifications were missing.
“The manager had delegated the checking and processing of incident forms to a member of staff.” from the report
- 01How are all safeguarding concerns and allegations of harm recorded and reported to the local authority and the CQC?
- 02What checks now make sure people who need supervision are not left without staff present?
- 03How are incidents investigated, reviewed and used to prevent repeat harm?
- 04How do you check that staff wear protective equipment correctly and clean equipment between people?
- 05What progress has been made on the action plan and when was the last review of these improvements?
This was a focused inspection of Safe and Well-led only; the other key question ratings were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 21 December 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, August 2018
St Leonards Court is rated Good; inspectors found kind, safe care, with staffing levels needing close monitoring.
This was an unannounced comprehensive inspection on 7 August 2018. Inspectors reviewed care records, medicines records, staff recruitment and training records, meeting minutes and quality checks. They spoke with people living at the home, relatives, staff, managers and a healthcare professional.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found that people were treated with kindness and respect. Their care plans were detailed and kept up to date. Medicines were managed safely, and people received support with food, drink and healthcare.
Staff were busy, and some staff felt stretched. Inspectors observed enough staff to meet people's needs in a timely way, but recommended that staffing levels continue to be monitored closely. The home had also fixed the earlier problem with bed rail covers, so it was no longer in breach of the regulations.
Kind and respectful care
Inspectors saw warm and compassionate relationships. Staff supported people without rushing them and respected their privacy and dignity.
“All staff were observed interacting with people with warmth and kindness.” from the report
Safe medicines support
Staff were trained and checked as competent to give medicines. Records and stock balances matched during the inspection.
“Storage of medicines was secure and stock balances were well managed.” from the report
Individual care plans
Care records described people's needs and preferences in detail. They were reviewed and updated when people's needs changed.
“Care records were detailed and person centred.” from the report
Improved safety oversight
The earlier problem with bed rail covers had been corrected. New checks were in place whenever care was provided to someone using bed rails.
“We checked all bed rails in use and found that they were well fitting and the bumpers with them were covering the rails safely.” from the report
Supportive management
People, relatives and staff described the management as approachable and supportive. The home used audits, meetings and surveys to monitor care.
“A range of quality assurance systems were in place to ensure monitor and improve the quality of care being delivered.” from the report
Staffing needed close monitoring
needs fixingSome care staff said they felt stretched and did not have enough time to spend with people. Inspectors saw enough staff during the visit, but recommended continued close monitoring.
“We recommend that the provider continues closely monitoring and reviewing staffing levels using an effective tool and through communication with staff to ensure people's needs continue to be met in a timely manner.” from the report
Dining arrangements
minorThe food was enjoyed and support was available, but tables were not fully prepared. Storage items were left on one table and napkins were not offered.
“However, tables were not set and on one table some storage items were left on the table during the meal.” from the report
- 01How do you check staffing levels when people's needs change, and what action do you take if staff feel stretched?
- 02How often are bed rails and their covers checked, and how are the checks recorded?
- 03How are meals, tables and dining support arranged for people who need help to eat or drink?
- 04How are activities adjusted for people who are tired, unwell or unable to join group activities?
- 05How will relatives be kept involved in reviews of care plans and changes in care needs?
This was an unannounced comprehensive inspection of the whole service, covering all five CQC questions and both the accommodation and personal care provided. This explanation was written from the published report of 18 August 2018 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 Court
4 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- December 2021Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2018Goodup from Requires improvementSafe: GoodWell-led: Good
- July 2017Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2015GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2013
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- October 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 23 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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
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.
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.