CQC report explained · a residential care home
What the CQC found at The Leylands - Residential Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Good
- People felt safe and staff understood how to protect them. Medicines, risk assessments, staffing and infection control were found to be safe.
- Effective?
- Requires improvement
- This key question was not inspected during this visit. Its rating was carried over from the previous inspection.
- Caring?
- Good
- This key question was not inspected during this visit. Its rating was carried over from the previous inspection.
- Responsive?
- Requires improvement
- This key question was not inspected during this visit. Its rating was carried over from the previous inspection.
- Well-led?
- Requires improvement
- Quality checks did not always identify inaccurate or contradictory records, and relatives were not always asked for feedback. The provider remained in breach of Regulation 17.
What inspectors found, March 2023
The Leylands - Residential Care Home is rated Requires Improvement; inspectors found safe care, but governance checks were not reliable and the home remained in breach.
This was an unannounced focused inspection on 7 February 2023. Inspectors looked only at Safe and Well-led because concerns had been raised about falls, moving and handling, and bullying. They spoke with people, relatives and staff, observed care, and checked care, medicines and management records.
Safe was rated Good, an improvement from the previous inspection. People said they felt safe. Medicines were stored and given safely, risks were assessed, staffing was sufficient, and infection prevention arrangements were in place.
Well-led remained Requires Improvement. The home did not always check records well enough to find inaccurate, inconsistent or missing information. It also did not consistently seek feedback from relatives. The home remained in breach of Regulation 17 on good governance.
The overall rating stayed Requires Improvement. This was the home's fifth consecutive inspection with this rating. CQC will request an action plan and monitor progress with the provider and local authority.
Safe medicines
Medicines systems had improved since the previous inspection. Records showed medicines were stored and administered safely.
“Medicines audits were comprehensive and effectively checked whether medicines were being stored and administered safely.” from the report
Risk management
Risk assessments gave staff clear instructions, including for people with specific eating and drinking needs. Staff knew how to respond to health concerns.
“Risk assessments in place provided clear guidance to staff on how to manage risks to people.” from the report
Enough staff
Inspectors found enough staff to meet people's needs safely. People said they did not have to wait for support.
“People were supported by an appropriate number of staff to meet their needs safely.” from the report
Supportive leadership
People, relatives and staff described the management as approachable and supportive. Staff had supervision and team meetings.
“The provider promoted a positive and open culture at the service which enabled staff to continue to learn.” from the report
Weak record checks
seriousRoutine checks did not always identify inaccurate clinical records, contradictory consent information or other gaps in documentation. This was linked to the continuing governance breach.
“We found systems in place to assess, monitor and improve the quality and safety of the service provided were not always effective.” from the report
Limited family feedback
needs fixingRelatives were not always asked for feedback about the service. This made it harder for the provider to identify concerns and areas for improvement.
“Relatives told us they were not always asked for feedback but they were contacted if there were any concerns.” from the report
Inconsistent documentation
needs fixingSome records were completed inaccurately or inconsistently. Inspectors found a consent record that gave conflicting information about a person's capacity, although no impact on that person was found.
“People's care files were reviewed regularly. However, checks did not always identify where documentation was contradictory.” from the report
- 01What actions are in the Regulation 17 improvement plan, and when will each action be completed?
- 02How are daily records now checked for accuracy, consistency and the escalation of clinical concerns?
- 03How will you check that consent and best-interests records do not contain contradictory information?
- 04How are relatives now being asked for feedback, and how will you show that their views lead to changes?
- 05Which ratings were carried over from the previous inspection, and when will the other key questions be fully inspected?
This was a focused inspection of Safe and Well-led only; the other ratings were carried over from the previous inspection. This explanation was written from the published report of 31 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, March 2022
Rated Requires Improvement; people were supported by trained staff, but medicines records and management oversight needed improvement.
This was an unannounced focused inspection on 13 January 2022. Inspectors looked at Safe and Well-led, spoke with people, relatives and staff, observed care, and checked care, medicines, recruitment and management records.
People generally felt safe. There were enough staff, people did not have to wait for support, infection control arrangements were in place, and staff understood people's needs. However, records for creams and some medicines did not always show clearly that medicines had been given.
The home had systems for checking quality, but these checks had not found the problems with medicines, recruitment records and a window restrictor. The window restrictor was replaced during the inspection and recruitment systems were improved. The overall rating remained Requires Improvement.
Enough staff
Inspectors found enough staff to meet people's needs promptly. People did not have to wait for care and support.
“There were sufficient staff to meet people's needs in a timely way and we observed people did not have to wait to receive support.” from the report
Staff understood people's needs
People were supported by trained staff who knew them well and understood their risks.
“People were supported by trained staff who knew them well.” from the report
Infection control
The home had arrangements for infection prevention, testing, protective equipment and visits. Inspectors were assured that these measures were in place.
“We were assured that the provider was using PPE effectively and safely.” from the report
Medicines records
needs fixingStaff who applied people's creams were not always the staff signing the records. This created a risk that records could say creams had been given when they had not.
“Where people were prescribed creams the staff administering these were not the staff that were signing the medicines records to reflect these had been applied.” from the report
As-required medicines
needs fixingSome staff did not have clear guidance about when as-required medicines should be given. Inspectors said this could lead to different approaches.
“Some people were prescribed medicines 'when required' such as paracetamol for pain relief.” from the report
Quality oversight
seriousThe home's audits had not found the problems identified during the inspection. This led to a breach of the governance regulation.
“Quality assurance tools in relation to medicines had not identified the concerns we found during the inspection.” from the report
Recruitment records
needs fixingRecruitment checks had been completed, but some files did not contain full employment histories. The provider improved its recruitment system after inspectors raised this.
“However, these checks required strengthening as staff recruitment files did not always contain staff's full employment history.” from the report
Window safety
needs fixingA ground-floor lounge window restrictor did not meet health and safety guidance. The home replaced it immediately during the inspection.
“During our inspection we found the window restrictor in the ground floor lounge was not compliant with Health and Safety guidance.” from the report
- 01What has changed so that the staff who apply creams also record them, or so that records are checked reliably?
- 02What written guidance is now in place for as-required medicines, and how do you check staff follow it?
- 03How do you now check recruitment files contain full employment histories?
- 04What action has been taken to improve quality audits and make sure they find problems promptly?
- 05How do you check that the window restrictor and other parts of the environment remain safe?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive carried over from the previous inspection when calculating the overall rating. This explanation was written from the published report of 3 March 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 The Leylands - Residential Care Home
7 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- March 2023Requires improvementcurrent ratingstayed Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
Read what inspectors found at The Leylands - Residential Care Home →
- March 2022Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
Read what inspectors found at The Leylands - Residential Care Home →
- October 2021Requires improvementup from InadequateSafe: GoodWell-led: Requires improvement
- April 2021Inadequatedown from Requires improvementSafe: InadequateWell-led: Inadequate
- February 2020Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- July 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2014
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- August 2012
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 9 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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