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Alveston Leys Care Home Good

Inspection Summary

Overall summary & rating


Updated 6 February 2018

This inspection took place on 19 and 20 December 2017. We returned on the 2 January 2018 so we could speak with the registered manager and look at their quality assurance systems.

Alveston Leys Care Home is registered to provide nursing and residential care for up to 60 people. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The home has a residential unit and a nursing unit which is spread over three floors. At the time of our inspection visit, 43 people lived at the home.

A requirement of the service’s registration is that they have 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 and the associated Regulations about how the service is run. At the time of our inspection visit there was a registered manager in post who was supported by a deputy manager.

At the last inspection on 7 February 2017, the service was rated as requires improvement. We found a breach of the regulations because improvements were needed in the deployment of staff. We also found improvements were needed in the processes and procedures to support the provision of quality care within the home. Following the last inspection visit, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions of Safe and Well led to at least good.

This inspection visit was a comprehensive inspection and during this inspection we checked to make sure improvements had been made. Whilst some improvements had been made, we found improvements were still needed to ensure daily records were accurate and clearly evidenced the care provided.

There were enough staff to provide safe and effective care that met people’s needs. Recruitment procedures ensured staff were qualified and safe to work with people who lived in the home. Staff understood their safeguarding responsibilities and the action they should take if they were concerned a person was at risk of harm.

The provider used a variety of risk assessment tools to identify any potential risks to people’s health and safety and risk management plans guided staff on how to manage those identified risks. However, daily records to support risk management were not being consistently or accurately completed.

Accidents and incidents were recorded by staff and analysed by the registered manager to identify any emerging trends or patterns so appropriate action could be taken to minimise identified risks.

People received care from staff with the knowledge, skills and competencies to support their health needs. Medicines were ordered, received, stored, administered and disposed of in accordance with good practice and overall, staff understood their role and responsibilities in relation to infection control and hygiene.

The provider assessed people’s capacity to make their own decisions if there was a reason to question their capacity. Staff and the registered manager had a good understanding of the Mental Capacity Act. Where possible, they supported people to make their own decisions and sought consent before delivering care and support. Where people’s care plans contained restrictions on their liberty, applications for legal authorisation had been sent to the relevant authorities as required by the legislation.

Staff supported people to eat and drink enough to maintain their health and referred people to other healthcare professionals when a need was identified. Managers and staff worked with other healthcare professionals to ensure people could remain at the home at the end of their life and receive appropriate care and treatment.

Staff were car

Inspection areas



Updated 6 February 2018

The service was safe.

There were enough staff to meet people's needs safely, and their suitability for their role had been checked before they started working at the home. Staff understood their responsibility to safeguard people from the risks of harm or injury and report any concerns they had. Systems were in place to ensure medicines were stored, administered and managed in accordance with good practice. The home was clean and tidy and staff knew how to support people in the event of an emergency.



Updated 6 February 2018

The service was effective.

People were cared for and supported by staff who had the skills and training to meet their needs. Staff understood their responsibilities under the Mental Capacity Act 2005. Where there were restrictions on people's liberty, the appropriate applications had been submitted to the local authority in accordance with the legislation. People were supported to eat and drink enough to maintain a balanced diet that met their needs and preferences. People's health was assessed and monitored and they were referred to other healthcare professionals when a need was identified.



Updated 6 February 2018

The service was caring.

People were content and happy and spoke positively about the friendliness and willingness of staff. Staff were kind, sensitive and caring in their approach and respected people's privacy and dignity. There was a relaxed and friendly atmosphere where people were encouraged to build and maintain relationships with each other and with family and friends. .



Updated 6 February 2018

The service was responsive.

Care and support was provided in a way people preferred and people and their relatives were involved in planning and reviewing their care needs. Communication care plans described people�s individual needs and how staff should engage with people to ensure they provided responsive care. People could remain at the home at the end of their life and received appropriate care and treatment. Complaints and concerns were dealt with in accordance with the provider's complaints policy.


Requires improvement

Updated 6 February 2018

The service was not consistently well-led.

Records to support risk management in the home were not being consistently or accurately completed. People and staff spoke positively about the leadership of the home but felt management could be more visible on occasions. The provider had systems and processes for reviewing the quality of the care provided and for gathering feedback from people and relatives to help it improve.