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Inspection Summary

Overall summary & rating


Updated 31 August 2018

This inspection took place on 8 August 2018 and was unannounced. Following our inspection visit to the home we spoke with relatives and other professionals on 10 and 14 August 2018.

At our last inspection in August 2017 we rated the service as Requires Improvement and found breaches of regulations 12 and 17. The breaches concerned the safe administration of people’s medicines and the effectiveness of the provider’s quality monitoring system.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions safe and effective to at least good. We found improvements had been made to return the service to a rating of good.

Leazes Hall is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The home can accommodate up to 48 people in one adapted building. At the time of our inspection 44 people were using the service including people with dementia and learning disabilities.

The care service had developed in line with the values that underpin the CQC guidance, 'Registering the Right Support' and other best practice guidance for people with learning disabilities. These values include choice, promotion of independence and inclusion.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Staff were assessed as competent before administering people’s medicines in a safe manner. We found the administration of people’s medicines complied with the guidance issued by National Institute of Health and Care Excellence.

Pre-employment recruitment checks were carried out by the service before staff began working in the home. When a new member of staff began to work in the home they were supported through an induction period, training and supervision. Staff training included how to safeguard vulnerable adults and staff knew how to do this.

The registered manager monitored the staffing levels to ensure the service could meet people’s needs. We found there was enough staff on duty.

Cleaning was on-going during our inspection to reduce the risk of cross infection. We found the home including people’s bedrooms and communal areas were clean and tidy.

Checks were carried out on a regular basis including fire safety to ensure people lived in a safe environment. People had individual emergency plans in place to help if emergency services evacuated people from the building. Adaptations had been made to the environment to support people living with dementia and promote their independence.

Personal risks had been assessed by the staff and actions taken to reduce risks such as falls. The registered manager reviewed in detail accidents and incidents which occurred in the home to see if they could be prevented.

Kitchen staff were aware of people’s dietary needs and prepared fluids and nutrition accordingly. We found the food was well-presented.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

Relatives were complimentary about the caring nature of the staff. Staff spoke to people in kind tones and respected their dignity and privacy. Care professionals who visited the home told us staff provided support when they visited and made sure people’s privacy was protected.

Activities were provided by the service. People were able supported to carry out activities of their choosing. These included outings, animal care

Inspection areas



Updated 31 August 2018

People�s medicines were administered in a safe manner by staff who were trained to do so.

Cleaning was carried out during our inspection. We found the home was clean and tidy.

Regular checks including fire prevention checks were carried out on the building and its contents to ensure people lived in a safe environment.



Updated 31 August 2018

Staff were trained and supported to carry out their roles. New staff underwent an induction to the service.

The service involved other healthcare professionals and took their advice to help meet people�s needs

Kitchen staff were aware of people�s dietary requirements and provided food and fluids to meet people�s individual needs.



Updated 31 August 2018

People, their relatives and other care professionals described staff to us as kind and caring.

People�s dignity and privacy were respected.

Relatives were able to be involved in the care of their family members through discussion with the staff. The registered manager provided a monthly newsletter.



Updated 31 August 2018

People�s needs were assessed and their care plans contained person-centred information.

The provider had a complaints process in place. Information was provided to people about on to make a complaint.

A range of activities was provided in the home to meet differing needs and preferences.



Updated 31 August 2018

Effective audit systems were in place to monitor the service and make improvements.

Surveys were carried out to measure the quality of the home. Responses to the latest survey were largely positive.

Relatives spoke with us about the registered manager welcoming them into the home and addressing any concerns they raised in a prompt manner.