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Leabrook House Nursing Home Requires improvement


Inspection carried out on 24 September 2019

During a routine inspection

About the service

Leabrook House is a care home providing personal and nursing care to 38 older and younger people at the time of the inspection. The service can support up to 41 people.

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

There was a lack of systems and processes in place that would provide the registered manager with oversight of the service. The few audits that were in place had failed to highlight a number of areas for action that were identified on inspection.

People’s opinions were not consistently sought and any feedback that was gathered about the service was not analysed for any lessons learnt, or information sharing.

People knew how to raise complaints and raised issues directly with the registered manager. However, people were frustrated with the lack of communication regarding how their complaint was being dealt with and what actions were being taken in response to the concerns raised.

People were supported by a group of staff who had been trained to recognise signs of abuse, but not everyone at the service who we spoke with, felt safe. One person raised a safeguarding concern with us during the inspection and the registered manager acted promptly and appropriately to this.

Staff were aware of the risks to the people they supported and how to manage those risks. Staff were observed to support people safely in line with their risk assessments.

People were supported by a group of safely recruited staff. The majority of staff had worked at the service for many years and knew people well. A recruitment programme was ongoing to recruit more staff and increase staffing levels.

People received their medicines as prescribed, administered by trained staff. Medicines were regularly audited, but audits had failed to identify some protocols were missing for ‘as required medicines’. Audits had identified a number of missed signatures on medication administration charts but there was no evidence available to demonstrate what actions were being taken in response to this.

Staff felt well trained and supported in their role. New staff benefitted from an induction that included shadowing more experience members of staff. Staff supported people to access a variety of healthcare services to help them maintain good health but did not consistently act on issues identified.

People enjoyed the food on offer and assistance was offered at mealtimes for those who needed it.

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

Staff were seen as kind, caring and compassionate and had positive relationships with the people they supported. Staff knew people well and what was important to them, however, there was little evidence to demonstrate that people had been involved in the development and review of their care plans.

People were supported to take part in a variety of activities that were of interest to them. Staff knew people well, what was important to them and how they wished to be supported.

For more details, please see the full report which is on the CQC website at

Rating at last inspection The last rating for this service was Good (published 6 June 2017).

Why we inspected

The inspection was prompted in part due to concerns received about care delivery and some allegations regarding thefts at the service. A decision was made for us to inspect and examine those risks.

We have found evidence that the provider needs to make improvements. Please see the Well Led section of this full report.

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

We found no evidence during this inspection that people were at risk of harm from this concern.


We have identified a breach in relation to good governance at this inspection.

Please see the ac

Inspection carried out on 29 March 2017

During a routine inspection

This unannounced inspection took place on 29 March 2017.

The home is registered to provide accommodation, nursing or personal care to a maximum of 41 people. People also access the service for short term respite care. On the day of our inspection 39 people were using the service. A high number of people who live there have needs associated with brain injury, illness or disability.

The previous ratings inspection of the service took place on16 and 20 March 2015 and at that inspection we found the service to require improvement in the area of Safe. This was because we found issues with the management of some medicines, which required improvement to prevent people being placed at risk of possible ill health. At this inspection we found that some improvements had been made to ensure the safe management of medicines.

The service had a registered manager. 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. The registered manager was available on the day of the inspection.

People living in the home felt safe. Staff were aware of the processes they should follow to minimise risk to people. Systems were in place to protect people from the risk of harm and abuse. Staffing levels and skill mix ensured that people’s needs would be met. Staff had been trained to manage medicines safely and people received their medicines as and when they should.

Staff had the skills and knowledge required to support people effectively. Staff received an induction prior to them working for the service and they felt prepared to do their job. Staff could access on-going training and regular supervision to assist them in their role. Staff knew how to support people in line with the Mental Capacity Act 2005 and gained their consent before assisting or supporting them. Staff assisted people to access food and drink.

Where possible people were involved in making their own decisions about their care and their specific needs. Staff provided dignified care and showed respect to people. People were encouraged to retain their independence with staff there ready to support them if they needed help.

Staff understood people’s needs and provided specific care. People’s preferences had been noted and acted upon where possible. People were given the opportunity to become involved in activities. People knew how to raise complaints or concerns and felt that they would be listened to and the appropriate action would be taken.

People were happy with the service they received and felt the service was led in an appropriate way. Staff were supported in their roles. Quality assurance audits were carried out, so that it was clear to see if any patterns or trends were developing which may impact upon the service provided to people. We received notifications of accidents or incidents that had occurred, which the provider is required to do so by law.

Inspection carried out on 16 and 20 March 2015

During a routine inspection

The provider is registered to accommodate and deliver personal and nursing care to a maximum of 41 people. At the time of our inspection 38 people lived there plus two people who were receiving respite care. Respite care is short term care to give family carers a break or for other reasons. People who lived there were of a wide age range (19-83 years old) and had varied and complex needs.

Our inspection was unannounced and took place on 16 and 20 March 2015. At our last inspection in 23 April 2013 the provider was meeting all of the regulations that we assessed.

A manager was registered with us as is required by law. 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.

We identified some medicine management issues that required improvement; however the manager was already aware of these issues and had started to take action to improve medicine safety. We found that medicine checks were undertaken but did not always identify specific problems with medicine safety. The manager was looking at developing a better checking system to address this.

Staff knew of the provider’s procedures that they should follow to ensure the risk of harm to people was reduced and that people received care and support in a safe way.

Most people and all of the relatives we spoke with told us that staff were available to meet their [or their family members] individual needs. Staff told us and records confirmed that they received in-depth induction training and the on-going support they needed to ensure they did their job appropriately and safely. We found that staff were trained and competent to support the people who lived there effectively.

Staff understood the requirements of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). We found that the registered manager was addressing the requirements set out in the MCA and DoLS to ensure that people received care in line with their best interests and were not unlawfully restricted.

Staff supported people with their nutrition and health care needs. We found that people were able to make decisions about their care and they and their families were involved in how their care was planned and delivered. Systems were in place for people and their relatives to raise their concerns or complaints.

The provider offered a range of recreational activities that people could participate in and most enjoyed. However, a re-evaluation of what is offered may meet a greater number of people’s needs. Staff supported people to keep in contact with their family as this was important to them.

Staff supported people to be as independent as possible. People who were able and willing were encouraged and supported to perform a range of daily living tasks and attend to their own personal hygiene needs.

All people received assessment and treatment when needed from a range of health care professionals including their GP, specialist consultants and nurses which helped to promote their health and well-being.

The registered manager had identified through monitoring and audits that record keeping required improvement and some policies and procedures were in need of updating. They had a plan of action and had started work to address this.

All people and relatives we spoke with told us that the quality of service was good and that it was a well-run home. The management of the service was stable, with processes in place to monitor the quality of the service.

Inspection carried out on 23 April 2013

During a routine inspection

There were 38 people living at the home on the day of our inspection. No one knew we would be inspecting that day.

All of the people we spoke with were satisfied with the care and overall service provided. One person said, “It is a good place”. Another person told us,” They are good and look after me”. Relatives were very complimentary they used words such as, “Marvellous” and “Wonderful” to describe the service provided. One relative said, “It is an amazing place. It was recommended to us. They have come on so well since they have been here”.

People's needs had been assessed which ensured that their health, personal care, and safety needs could be monitored and met.

Recruitment processes were adequate which gave people living at the home assurance that only suitable staff had been employed which had decreased the risk of them being harmed in any way.

People and staff we spoke with highlighted that there were enough staff to meet people’s needs and keep them safe. One person told us, “There are always enough staff around. We do not have to wait for anything”. We found that staff had been given training and support which had helped them to meet people’s needs and keep them safe.

Records we looked at and people we spoke with confirmed that systems had been used to monitor how the service had been run to benefit the people who lived at the home.

Inspection carried out on 2 April 2012

During a routine inspection

We arrived at Leabrook House at 06.15 hours so that we could indirectly/ directly observe or sample routines and care delivery from early morning. During our inspection we spoke with staff, managers and two relatives. We also spoke with five people living at Leabrook House. Below are a few examples of what they said to us;

“I was worried about coming into a nursing home. I thought they were for old people. It is brilliant though. I have no complaints. I am well looked after”.

“I am very happy here and have no complaints. I am happy with the building itself and the staff who look after me”.

We spoke with two relatives. They were complimentary about the care provided. One relative told us; “We were worried at first as they had not been in a home before. They settled so quickly and are so happy being here we do not worry anymore. We are happy with the care; we do not have any complaints. The staff are very good, they are kind and caring. We are always kept informed if there are any changes or problems”.

Another relative told us; “This place is second to none. I can not fault it. No problems at all”.

We spoke with a number of staff below are some of the comments they made;

“I think everyone is safe and well cared for. I have had experience of other homes and in comparison this one is outstanding”.

“I have worked in other homes, this one is the best one yet”.

Reports under our old system of regulation (including those from before CQC was created)