Welcome House - Leeza Court

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 Inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to safe care and treatment, and safeguarding service users from abuse or neglect. This meant there were widespread and significant shortfalls in people’s care, support and outcomes.

This service scored 34 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice. The provider had not acted with openness, and allegations of abuse or neglect were not reported as safeguarding referrals or notifications submitted to CQC. One member of staff stated, “If an incident happened, we would only report it if we can’t resolve it ourselves”. This failed to recognise the legal responsibility of the provider to act with candour and openness.

Whilst incidents were recorded and staff were confident in how to do so, opportunities for learning were missed and there wasn’t a clear system to analyse trends or themes from incidents to prevent them happening in the future. Where people had expressed intentions around suicide or self-harm, people’s risk assessments had not been updated to reflect a clear plan for how staff should support people. For example, one person was at significant risk of harm due to their declining mental health, and a dedicated member of staff had been put in place to support them. However, there was no clear guidance on what this member of staff should do, and the staff we spoke with expressed different opinions in how they would support this person.

The provider did not work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services. People lived with significant mental health needs, but there was no guidance on how staff or the service would respond if somebody was in a mental health crisis including at which point they may need to seek involvement from other professionals to ensure people’s safety. Documentation did not clearly reflect people’s current mental health needs and where people had expressed thoughts in relation to self-harm it was not clear if any support had been sought around this.

We found not all health conditions had clear guidance in place for staff for follow or when to seek specialist input. For instance, one person had diabetes but there was no guidance around how staff would identify potential signs and symptoms of a deterioration in their condition. Where people had respiratory difficulties such as asthma, there was no clear advice about how to support people to keep them well, or how staff should respond in the event of an asthma attack including when they may need to seek medical advice. Further improvements were needed so there were clear pathways in place for all people’s health conditions.

We saw there were some appropriate referrals to partner organisations had been made to support people to manage some aspects of their health effectively. For example, where people were at risk of falls, referrals had been made to occupational therapy to support people to mobilise more safely. Similarly, people at risk of malnutrition had been referred to the dietician for specialist advice, their weight monitored. People were supported by staff to attend health appointments. One relative told us “My relative had a blip earlier this year. Staff worked with health services to review her medication, and I think she’s fine now”.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not 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 share concerns quickly and appropriately.

Where allegations of abuse or neglect had been made, the provider did not understand their responsibility to formally report these to the local authority safeguarding team. When partner agencies are not informed, people at significant risk of harm are deprived of the appropriate action needed to ensure their safety. We identified at least 7 incidents in 2025 which met the threshold for a safeguarding referral, yet none had been reported. Some people at the service were documented to make allegations of physical, emotional or financial abuse which were felt to be false, however, there was no clear guidance in place around how this should be managed. This meant there was a significant risk that any genuine instance of abuse would not be identified or investigated appropriately. Where people had experienced abuse in their own lives prior to moving to the service, there was a lack of clear guidance to support staff to spot the signs of potential reoccurrence.

Staff had received safeguarding training and could describe the signs of abuse and neglect, and how to report any concerns about people’s wellbeing. However, the service had not recognised or responded when this had occurred. People had attempted to commit self-harm, been physically or verbally abused by other people, or made allegations about staff without these being reported. One member of staff told us “No, there have been no allegations of abuse or neglect at the service whilst I have worked here”. This was despite us identifying multiple allegations.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. We found people were living with complex mental health conditions without clear guidance for staff on how to support their mental wellbeing, or how to respond if a person became distressed. This meant people were supported inconsistently. In the case of one person, whose health would be put at significant risk if they drank alcohol, their care plan stated staff would encourage them not to drink. However, there was little information on how staff would do this, and several staff members told us they would give them alcohol if they were distressed. One staff member told us, “It’s just about giving (person’s name) whatever they want; I wouldn’t try to discourage them from drinking”.

Some people were at risk of becoming physically aggressive, however, there was no clear guidance for staff to follow to de-escalate and protect themselves and other people from harm. Neither could staff confidently describe how they would de-escalate a situation to avoid a person becoming physically aggressive, meaning people and staff were potentially at risk of significant harm.

Most people at the service were at risk of self-harm and potential suicide. However, there was no staff guidance in place to manage such risks. One person had recently verbalised the wish to end their own life on at least 3 occasions within the calendar year, but their care plan stated they were not at any risk of suicide. This showed that their care plan and risk assessment had not been appropriately updated to reflect their current needs.

People were living with complex health conditions such as diabetes, constipation, asthma and COPD with no risk assessment in place to support staff on how to manage these conditions to keep people safe. This meant people were exposed to a greater risk of harm as staff did not have clear information on how they would respond if a person’s health were to deteriorate. For example, one staff member told us they would not know how to respond if a person had a seizure. Another staff member told us they would only call the GP after a person had been constipated for 7 days, not recognising the significant risk of harm such a delay would cause.

The provider did not 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. Although we found the environment was well maintained, the provider had not assessed all the risks to people or put in place appropriate measures to protect people from harm. Whilst fire risk assessments were completed, these were completed based on people not smoking in the building which we found was not the case. One person smoked in their room and would regularly become intoxicated, and another person smoked and was prescribed emollient creams which were extremely flammable. There was no fire risk assessment for either person. Despite people being assessed at risk of self-harm or suicide, the provider had not conducted a ligature risk assessment of the environment with unsecured cables present through the building. Once we raised this concern with the provider, appropriate action was taken to put risk assessments in place in these areas.

The provider did conduct regular checks on wider risks in the environment such as electrical, water and gas checks. Any equipment being used was also regularly reviewed and serviced. There had been recent improvement works in the garden, although we recommended further work be conducted as the uneven surface meant not all areas were easily accessible or safe for people who had limited mobility.

The provider did not 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. Staff were not always provided with sufficient information to be able to safely support people with their mental health or physical needs. Whilst there was a designated key worker in place for each person, these staff were not always fully aware of people’s current health needs and how to support them. Staff told us they were worried about specific risks to people and had been raising these concerns to management, however they had not been informed that referrals to specialist services had been made or what the outcome of these was.

Staff had not completed all training relevant to their role and the people they supported. This impacted people’s safety. For example the majority of people we reviewed had limited mobility which placed them at risk of falling, but staff had not undertaken training around falls prevention. When we asked how staff would respond if people were exhibiting aggressive or threatening behaviours, staff could not clearly articulate how they would respond to this to keep themselves and others safe. We were not assured that knowledge on de-escalation or support for people in a mental health crisis was sufficient, or around specific risks to people such as how to support people with an alcohol addiction.

However safe recruitment practices were followed when new staff were employed. We observed that if people wished to go out into the community there were enough staff to support this, and the manager would undertake care duties or bank staff would be sourced if required to ensure there were another staff remaining at Leeza Court.

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. Staff could confidentially describe the steps they would take to prevent the spread of infections including by wearing personal protective equipment (PPE). People were supported and encouraged to take part in cleaning the space they lived in independently and were assisted by staff where needed. We found the environment was clean and that there were regular checks conducted by management to ensure cleaning was being completed regularly. One relative told us, “Yeah, I feel it is clean. My relatives room seems fine and doesn’t smell”.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. The risks associated with some specific medications were not always managed safely. One person, who would regularly drink alcohol and take prescribed antipsychotic medicine at the same time, was at a higher risk of ill health, yet there was no guidance for staff about how to monitor this or what the potential side effects could be. The fire risks posed by smoking whilst being prescribed emollient creams were also not well understood or risk assessed. Where people were being given “as and when” medications including antipsychotic drugs, laxatives and painkillers, staff were not recording if these had been effective in line with best practice.

Other aspects of people’s medications were being managed safely. Staff were sufficiently trained and competent to support people, and medications were being stored, administered and recorded safely in most cases. The service were proactively requesting reviews of people’s medication, for example for one person who was prescribed a significant amount of medicines to ensure that these were all still needed.