St Leonards Rest Home

Updated 18 January 2023

The inspection

This was a targeted inspection to check on a concern we had about the day-to-day management oversight in place in relation to ensuring people’s welfare and governance.

Inspection team

The inspection was carried out by 2 inspectors.

Service and service type

St Leonard’s Rest Home 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. St Leonard’s Rest Home 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 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 a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

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 reviewed information we had received about the service since the last inspection and used information gathered as part of monitoring activity that took place on 22 March 2022 to help plan the inspection and inform our judgements. We used all this information to plan our inspection.

During the inspection

We visited the service and met all of the people being supported. We spoke with the care manager at the service and viewed the staffing rota. We viewed the shared spaces of the service. Following the site visit we had a telephone call with the provider to get assurances about the arrangements in place to ensure there was effective oversight of the support and governance of the service.

Updated 18 January 2023

About the service

St Leonards Rest Home is a residential care home that provides accommodation for up to 15 older people who may require personal or nursing care. At the time of the inspection 12 people were being supported and some people were living with dementia or other cognitive impairments.

During our previous inspection in October 2019 we identified five breaches of regulations. We took enforcement action and issued two warning notices. This was to ensure effective systems were operated to ensure compliance with regulations and to monitor and improve the quality of the service provided. At this inspection we found enough improvements had been made; however, there was a need to sustain the improvements made and to make further improvements. The service has been rated as requires improvement as it met the characteristics for this rating in the two inspected key questions. More information is in the full report.

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

Overall enough improvements had been made to protect people from the risk associated with poor prevention and control of infection, in the providers understanding of safe operating procedures and in the monitoring and improving the quality and safety of the service.

Improvements were still needed to ensure the provider followed their infection control and prevention procedures. We have made recommendations about some waste disposal, storage areas and the garden areas of the service.

Since the previous inspection the provider had improved their quality assurance audits however improvements were still needed to ensure they were effective. We have made recommendations about reviewing their safeguarding and quality assurance systems in line with best practice.

People told us they felt safe. Medication administration records (MAR) confirmed people had received their medicines as prescribed. The emotional well-being of people during the COVID-19 pandemic had been prioritised by the provider.

Staffing levels were meeting the care needs of people living in the service. Recruitment records showed staff were recruited safely and in line with current legislation. Staff felt supported and were positive about the internal improvements that had been made to the service since the previous inspection.

The provider was engaging with external professionals to address fire safety concerns and to update their care planning documentation.

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

Rating at last inspection and update

The last rating for this service was inadequate (published 09 April 2020) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection we found enough improvements had been made and the provider was no longer in breach of the regulations in four of the five previous breaches.

This service has been in Special Measures since April 2020. During this inspection the provider demonstrated that enough improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 08 October 2019. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

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 coronavirus and other infection outbreaks effectively.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from inadequate to requires improvement. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for St Leonards Rest Home on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service.

We have identified a breach in relation to the provider failing to comply with the requirement to display their rating appropriately at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.