Leabrook Lodge Limited

Updated 19 May 2023

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.

Inspection team

This inspection was carried out by 1 inspector.

Service and service type

This service provides care to people living in specialist ‘extra care’ housing. Extra care housing is purpose-built or adapted single household accommodation in a shared site or building. The accommodation is bought or rented and is the occupant’s own home. People’s care and housing are provided under separate contractual agreements. CQC does not regulate premises used for extra care housing; this inspection looked at people’s personal care and support.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was not a registered manager in post.

Notice of inspection

We gave the service 24 hours’ notice of the inspection visit because it is an extra care housing scheme and the provider is often out of the office supporting staff or providing care. We needed to be sure they would be at the office to support the inspection process.

Inspection activity started on 3 April 2023 and ended on 25 April 2023. We visited the location’s office on 5 and 21 April 2023.

What we did before the inspection

We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make.

We asked the local authority and Healthwatch for any information they had which would aid our inspection. Local authorities together with other agencies may have responsibility for funding people who used the service and monitoring it’s quality. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. We used all of this information to plan our inspection.

During the inspection

We spoke with 1 person who used the service about their experience of the care provided. Additionally, we spoke with 2 other people about the management of the location.

We spoke with 5 staff members including carers, directors and the newly identified care manager.

We reviewed a range of records. This included 1 person’s care plans and records of medicines administration. We looked at a variety of documents relating to the management of the service, including quality monitoring checks. We reviewed the files of 4 staff members.

Updated 19 May 2023

About the service

Leabrook Lodge Limited is an extra care housing scheme that provides personal care and support to people living in their own bungalows in a large community. The office base was on site and staff were on hand 24 hours a day to respond if required.

Not everyone who used the service received personal care. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do, we also consider any wider social care provided. At the time of the inspection 1 person was receiving personal care.

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

People were not safe as the provider failed to identify and assess the risks associated with their care and support. The care and support plan failed to provide staff members with the information needed to ensure people received safe care which met their needs.

People could not be assured they received their medicines safely. The provider failed to complete protocols identifying the specific medicines people took including the provision of ‘as required’ medicines.

The provider did not have effective systems in place to review incidents, accidents or significant events to see if something could be done differently.

The provider did not have effective systems in place to identify improvements and drive good care. People were not asked about their experiences of care or effectively engaged with developing the service they received.

People were protected from the risks of ill-treatment and abuse as staff had been trained to recognise potential signs of abuse and understood what to do if they suspected harm or abuse. However, the provider needed to provide people, relatives and visitors with information on how to raise any concerns they had.

People were supported to have maximum choice and control of their lives and the provider supported them in the least restrictive way possible and in their best interests; the application of the policies and systems supported good practice.

People were supported by staff who arrived when expected and stayed for the agreed amount of time. The provider followed safe recruitment checks when employing staff.

For more details, please see the 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 good, published on 28 August 2019.

Why we inspected

The inspection was prompted in part due to concerns received about the overall management of the service. A decision was made for us to inspect and examine those risks.

This report only covers our findings in relation to the key questions safe and well led.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe and well led sections of this report.

You can see what action we have asked the provider to take at the end of this report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Leabrook Lodge Limited on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to keeping people safe and with the overall management of the care provision.

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.