Updated 15 September 2025
Date of Assessment: 14 October 2025. Leahyrst Care Home provides personal care to up to 40 people, some of whom were living with dementia. At the time of our assessment 38 people were using the service. The home is split between 3 separate units, across several floors. We carried out a comprehensive assessment due to the rating and a previous breach of legal regulations in relation to governance. At this assessment the service has remained rated requires improvement, with a continued breach of regulations in relation to governance and a further breach of regulations in relation to managing risks posed to people.
Risks posed to people were not always managed effectively. Care records did not always contain enough information or accurate information in relation to people’s needs, meaning staff did not always have up to guidance about how to keep people safe. Daily records did not always reflect evidence people’s care and support had been carried out in line with their needs. We found no harm to people, and this was found to be a recording concern. Refurbishments were required in some parts of the service, and we found some infection control practices which did not promote safe infection, prevention and control measures. Medicines were not always stored appropriately and some medicines records and stock checks required improvements. However, staff completed medicines administration records (MAR’s) appropriately and staff received adequate training and competency assessments prior to administering medicines to people. Accidents and incidents were recorded by staff, however there was a lack of oversight and monitoring of these, to enable the service to learn lessons. People were protected from the risk of abuse and staff understood their responsibilities to report poor practice. The service was not always working within the principles of the mental capacity act (MCA). Where people are deprived of their liberty, appropriate authorisation should be in place, we found some delays in requesting these and where people had conditions in place, these were not always being met. People were supported by enough suitably qualified staff and staff were recruited safely.
Improvements were required to ensure each person had a robust assessment of their care needs and up to date care plans in place. We could not be assured people were provided with a continuity of care, due to the concerns we found in relation to records. Information shared with partners who worked with the service could be incorrect and/or be missing key information about their needs. People told us they enjoyed their meals, and a varied menu was on offer each day.
People were encouraged to give feedback about their care and support, and this was used to make improvements for people and provide them with good outcomes. People, staff and relatives felt listened to. The service had no recent formal complaints at the time of our assessment; the registered manager understood their responsibilities to manage complaints as they should arise. People had access to external healthcare professionals where required. People enjoyed a range of activities, which included in house games and community outings. Partners who worked with the service gave us positive feedback about the care people received.
Governance systems were not robust enough and did not identify the concerns we found during our assessment. We could not be assured leadership was effective due to concerns we found in relation to managing risks, infection control, environmental risks, and care planning. Staff felt supported in their roles and told us the registered manager was approachable and fair. Staff wellbeing was promoted. The registered manager was open and honest with us throughout our assessment and was keen to drive improvements in the service. There was an ongoing quality improvement plan in place.