Leighton House Retirement Home Limited

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 good. At this assessment the rating has changed to 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 the ways people’s medicines were managed and the recruitment processes
 

This service scored 59 (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. Lessons were not always learnt to continually identify and embed good practice.

Accidents and incidents were documented and discussed with staff and management. The registered manager explained the process in place in the event of an incident which included looking at the cause and planning to mitigate the risk of this in the future, however there was limited documentation to support this. We saw evidence of some risk assessments being updated following incidents, but this was not always consistent, and some risk assessments were not in place. There was limited evidence that the information obtained following accidents was reviewed and analysed to drive improvements within the home.
 

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

People’s needs were assessed by the registered manager before they moved into the home. Relatives were encouraged to participate in this assessment when appropriate. This ensured their needs could be met by the home.

The home worked closely with the local GP practice and a clinician visited the home on a weekly basis. Referrals were made to other healthcare professionals such as Speech and Language Therapy (SALT). A follow up phone call to the healthcare professional was completed by the registered manager as well as the relevant information in writing.
 

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

Overall, people said they were happy with the care provided and they felt safe. One person said, “I feel safe here because there's no aggravation. It's peaceful. I feel that there are enough staff as well. There is somebody always on hand to help me.”

Staff received safeguarding training and could recognise signs of abuse. Staff said they felt able to raise concerns and understood the procedure for reporting any safeguarding concerns. However, some accidents and incidents had not been referred to the local authority, ensuring appropriate action was taken to help protect people and keep them safe. Also, notification of events had not always been provided to CQC, as required by law.

One person told us that although they felt safe, the behaviours of another resident had caused them concern. Although some action had been taken in response to these behaviours, a thorough exploration to understand and reduce them had not taken place.

Policies and procedures for safeguarding adults, the Mental Capacity Act (MCA) were in place. People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. This can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the MCA. We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. The information around DoLS had recently been reviewed to ensure all the details were accurate and up to date. Applications to legally deprive people of their liberty had been made to ensure any restrictions on people were lawful.
 

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Care records contained relevant risk assessments, which assessed risks to people, such as the risk of choking, falling, or behavioural risks and explained how these should be managed. People identified as being at an increased risk of falling had specialised equipment such as sensor mats in their bedrooms.

The registered manager explained how they promoted positive risk taking within the home whilst managing risks effectively. For example, a resident who enjoyed walking to the shops was provided with a business card with all the relevant details on to ensure, in the event of any incident, the correct care and support could be provided, and the home could be contacted.
 

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.

The home had been inspected by the fire service in March 2025, and several areas were identified as non-compliant. One of the issues identified was the presence of locks on all the bedroom doors. The locks had since been removed for all but 3 of the people living in the home who had chosen to retain their locks. Each person now had a personal evacuation plan which explained to staff what support they needed to safely evacuate the premise in the event of a fire. Most of the necessary changes identified by the fire service had been implemented with any outstanding work scheduled.

The lift was a risk due to it being accessible to people living in the home who may not be safe to do so unsupervised. The registered manager had contacted the lift company and was awaiting a keypad to be installed to manage this risk.

Areas of the home were cluttered with stair lifts which were not being used and causing an obstruction. A hoist was also being stored in the upstairs dining room which obstructed part of the room and was a potential trip hazard.

The relevant safety checks had been completed including gas and electricity. The local authority had recently identified noncompliance with checks and training regarding legionella, however, this had now been addressed by the registered manager.

Some areas of the environment needed improvement, for example there was broken furniture in some bedrooms, bathrooms and communal areas. The registered manager confirmed replacement furniture had been ordered, and further work was scheduled to improve the standard of the home, including the replacement of ceiling tiles.
 

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support,
supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

The registered manager ensured new staff received an induction, however this was completed within a much shorter time frame than the policy indicated. Robust recruitment records were not maintained. There was no evidence of interview records, so we were unsure how suitability for the role had been determined. Two personnel files contained only a single reference and a staff member had commenced work before all their background checks had been received.

Staff we spoke to were knowledgeable and experienced. A review of the rotas showed adequate numbers of staff were available to meet people’s needs.
 

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

There was an infection prevention and control (IPC) policy in place, and the home was generally clean and tidy. Prior to the assessment, the local authority had identified several IPC concerns. Several improvements had been made and where there was outstanding work the relevant companies had been contacted.

Personal protective equipment (PPE) was available for staff and there had not been any recent outbreaks of illness within the home.
Hand sanitiser was not available due to the current stock being replaced, however there were no temporary bottles of sanitiser in the home to use in the interim.
 

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Medicines were stored safely. The remaining quantity of medicines showed the medicines had been administered as prescribed. However, medicines that required administration at specific times, including in relation to food, were not always administered in line with the manufacturer’s instructions. Where medicines required a specified time interval between doses, this was not always observed. This placed people at risk that medicines may not work as intended and increased the risk of side effects.

Where people were prescribed more than one ‘when required’ medicine for the same condition, such as analgesia, information was not always available to support staff to administer these medicines safely.

Where medicines were prescribed with a variable dose (for example, take 1 or 2), guidance was not always available to support staff to select the appropriate dose. This increased the risk that people may not receive the most appropriate medicine or dose.

For people prescribed medicated patches, manufacturer instructions regarding site rotation were not consistently followed. This placed people at risk of skin irritation and side effects.
The care records did not always include detailed information around specific health conditions to support staff to safely care for people.

The service did not consistently follow best practice guidance, including the National Institute for Health and Care Excellence (NICE) Managing medicines in care homes. We saw the information to support safe administration of medicines in relation to food was not included on the Medicines Administration Record (MAR), nor was people’s allergy information. Staff did not always follow the service’s medicines policy to ensure medicines were managed safely, for example when people were prescribed more than one medicine for the same condition.

Systems and processes to assess, monitor, and improve the quality and safety of the service were not effective. Audits failed to identify all issues found during the inspection.