Leighton House Retirement Home Limited

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement.
This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to governance at the service
 

This service scored 61 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The home had a mission statement and all the staff members we spoke to clearly understood what the home wanted to achieve. Regular staff meetings and a culture of open communication ensured staff were supported to provide care in line with this vision. The registered manager was visible and involved in people’s care, leading by example and helping to promote the desired culture within the home.
 

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively.
The registered manager was experienced and passionate and staff spoke positively about them confirming that they have regular meetings and felt supported.
Everyone spoke positively about the way the service was managed. A relative said, (registered manager) is very approachable and it's a well-managed service. (Registered manager) listens to me and would try to take appropriate action.” A healthcare professional from the local hospice said they had “no concerns about care” and they had “confidence in the service (and) know they will call when support is needed”.
However, the required recruitment checks had not been completed which meant we could not be assured about the suitability of people employed in the home. The audits and reviews that were completed by the registered manager did not highlight the issues found at inspection. We fed this back to the registered manager who understood the importance of improving these processes.
In addition, we did not see any evidence that the registered manager currently attends any training or networking to ensure they were aware of relevant changes in guidance and legislation.
 

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.
The provider had a whistleblowing policy which staff confirmed was in place and on display, should they wish to raise concerns about the home or management. Staff told us they felt comfortable to raise any concerns and they would be listened to.
Regular meetings provided opportunities for staff to raise any concerns that they may have.
 

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The registered manager understood the importance of promoting an inclusive workplace, where staff were treated equally and fairly. Policies were in place to ensure equality and diversity were promoted and staff said that they had no concerns about the way they were treated.
 

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Audits were conducted in various areas including falls, medication and health and safety. However, these audits did not always identify areas of inconsistency or concern. Where issues were identified there was not a clear process to use this information effectively and to manage the existing risk.

Care plans were reviewed but not consistently updated when people’s care needs changed. One person’s mobility had declined but their risk assessment and care plan had not been updated to reflect this, placing this person at risk. Although a review of their care plan had been completed, this had not been highlighted. The same person had limited communication and used hand gestures. Although the staff were aware of this, a review of their care plan had not identified this important information was missing, which could prevent this person from being understood.

Recruitment records were incomplete which had not been identified by the registered manager. This meant we could not be sure that risks and suitability of staff had been correctly assessed.

Notifications about incidents were not always submitted to CQC as required. We spoke to the registered manager about this who has acted on the feedback provided. We did not see evidence of spot checks to manage current performance, however staff said they felt the service was well managed and the registered manager was regularly visible in the home and involved in people’s care.
 

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The registered manager worked with a number of professionals including the GP, physiotherapists and the local hospice to ensure people received appropriate care and support. One relative told us, “Opticians, dentists and podiatrists visit here”.
 

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

We did not see evidence of continuous learning and striving for improvement in the home. Accidents and incidents were logged and filed under each person but there was no clear plan outlined to reduce incidents and improve outcomes for people.

Audits and reviews did not identify issues that we found during the assessment so we could not be assured that the processes in place identified areas that needed attention and improvement.

People living in the home were happy, however some felt that as people’s needs had changed the home had not developed accordingly. One person said, “This place has changed so much since I came to live here at first. It used to be like a holiday camp with things happening all the time and there were many residents who had mental capacity. They had different physical conditions but there weren't many living with dementia, whereas now everyone has it here.”

Relatives were encouraged to provide feedback and suggestions using surveys and the registered manager also spoke regularly to people living in the home, and their visitors. One family member said, “I've had a questionnaire about my levels of satisfaction, but I'm not aware of any meetings. I'm happy with this home and would recommend it because it's homely, the staff are approachable and genuinely friendly.”