Leighswood

Updated 16 September 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

Two inspectors carried out this inspection.

Service and service type

Leighswood is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Leighswood is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided. At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We used information gathered as part of a monitoring activity that took place on 18 October 2021 to help plan the inspection and inform our judgements. We reviewed information we had received about the service since the last inspection, under the previous provider. We sought feedback from the local authority and Healthwatch. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England.

The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke to 10 people and four relatives about their experience of the care provided. We spoke with one professional who regularly visits the service. We spoke with 12 members of staff including the directors of the provider and the nominated individual, the area manager, registered manager and eight members of staff at the service. We reviewed a range of records. This included five people’s care plans, medicine administration records (MAR) and two staff recruitment files. We viewed a variety of records relating to the management of the service including audit systems.

After the inspection

We continued to seek clarification from the provider to validate the evidence found. We looked at a range of documents including staff rotas and the provider’s improvement plan.

Updated 16 September 2022

About the service

Leighswood is a residential care home providing accommodation and personal care for up to 23 people, including people with dementia. At the time of our inspection there were 21 people using the service.

People’s experience of using this service and what we found

People were not always protected from fire risks or the spread of infection. People and staff didn't always feel there were enough staff, although we found people's needs were met in a timely way. Systems were in place to safeguard people from abuse and the provider had established processes for learning lessons when things went wrong.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

People's needs and choices were assessed and the service ensured people's dietary needs were well met. However, people's oral health needs were not individually documented. The new provider had taken steps to improve the environment for people. People were also supported to access healthcare and external support as needed.

People did not always feel there were enough activities to keep them occupied. However, the records showed a range of activities had previously taken place. The provider had recruited an activity coordinator to establish further activities for people in the future. People's communication needs were considered and catered for. Systems were in place to seek feedback and resolve people's complaints.

Quality assurance systems were not always effective for people. This meant the action taken by the provider had not always ensured people received consistent, good and safe care. The provider was working to improve the systems and processes in place and provide a positive culture for people at Leighswood.

People were supported in a caring and dignified way by staff. We saw people having positive interactions with staff, who sought to comfort and reassure those in distress. People felt staff knew them well and were supportive.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for the service under the previous provider was requires improvement, published on 09 October 2020. This is the first inspection for this service under a new provider.

Why we inspected

This inspection was prompted by a review of the information we held about this service. We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We have found evidence that the provider needs to make improvements. Please see the safe, effective, responsive and well led sections of this full report. The provider took immediate steps to address the concerns identified following the inspection.

Enforcement

We have identified breaches in relation to the how people’s safety was managed, their rights promoted and how the service was run at this inspection. Please see the action we have told the provider to take at the end of this report.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.