Leahyrst Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to managing risks posed to people.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice. Whilst we found incidents were recorded, there was a lack of oversight. The management team did not analyse incidents for themes and trends, and it could not be evidenced action was taken following incidents, to prevent them from happening again.

The provider did not always make sure there was continuity of care, including when people moved between different services. Some care plans contained conflicting and missing information about people's needs. We could not be assured people would receive safe pathways and transitions, as partners may not be provided with up-to-date information about people's needs and wishes.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately. Staff understood their responsibilities to report concerns and told us they felt comfortable to whistle blow on poor practice. Staff were trained in relation to safeguarding vulnerable adults. People told us they felt safe living at the service. A person said, “I have been here quite a while, and I have always found the staff to be good. They go out of their way to make sure we are okay." A relative said, “The care is great here. Really good. [Name] has been here for nearly a year now and I've no worries at all. Staff are really helpful."

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). The service was not always working within the principles of the MCA. We found some DoLS conditions were not being met and there were some delays in requesting renewals.

The provider did not work well with people to understand and manage risks. Risks posed to people were not always mitigated. Records were not always consistent or reflective of people’s current need. For example, we could not be assured a person had received always appropriate care in line with their care plan to reduce the risk of pressure damage and information in relation to the use of hoist slings lacked detail. Where people received modified diets, to mitigate their risks of choking we found this was provided to people. However, records contained conflicting information about individual needs. This could be confusing for staff and posed a risk of staff accessing guidance which was incorrect and people receiving care which could put them at significant risk of harm.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. We found several radiators which were exposed, and were hot to touch, this posed a risk of scalds and burns to people. This was discussed with the registered manager on the day of our assessment, and we were assured these concerns were rectified. The service was in need of redecoration and refurbishment. We observed several furnishings to be tired and areas of the home which required painting. Fire safety measures were in place; however, we found some personal evacuation plans which did not contain enough information about people's needs in the event of a fire. Other maintenance checks were in place, to ensure equipment was safe for use, such as lifting equipment, electrical equipment and bed rails.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. People and relatives told us staff knew them well and met their needs. A person told us, “It’s good here. The staff are always very helpful and pleasant." A relative said, “They are doing a good job here. There are a lot of familiar staff which really helps with [name’s] dementia." Staff were recruited safely, and all pre-employment checks were in place. New staff received an induction and shadowing opportunities. Staff were suitably trained, to enable them to carry out their roles effectively, this included training in relation to emergency first aid, dementia and pressure care.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading. Whilst the environment was found to be mostly clean and tidy, some infection control practices required improvements. We found areas of exposed wood, which could not effectively be cleaned, shared jugs and urine bottles in bathroom areas and some shared toiletries. Some areas of the service were observed to have malodours. Staff were observed to wear personal protective equipment (PPE) as required and handwashing facilities were available throughout the home.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. We found some creams stored in people's rooms, which did not contain open dates, meaning we could not be assured these creams were safe for use. We also found a tub of cream which did not belong to a person, in their room. Some medicines items were stored in a fridge, the thermometer in place was not in line with best practice requirements and we found several days where the fridge was too high in temperature. Medicines did not always have open date labels, such as liquids and ointments. Where people were prescribes ‘as required’ medicines, protocols were in place. However, improvements were required to ensure they contained enough detail about time between dosages. Where people were prescribed controlled drugs, these were not regularly checked, to ensure stock was correct. However, we did find stock levels were correct for controlled drugs and other medicines. Staff completed medication administration records (MAR's) accurately, including the effectiveness of ‘as required’ medicines.