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Inspection Summary

Overall summary & rating


Updated 24 March 2020

About the service

The Leys is a residential home providing care and support for older people and people with dementia. The service is registered to provide personal care to up to 33 people. At the time of inspection, they were supporting 26 people.

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

The leadership and the management of the service had not made enough improvements to the safety and governance of the service since the last inspection.

There was a continued lack of understanding, oversight and governance systems to ensure people received a safe service. Systems that were in place were not implemented effectively and audits did not identify ongoing concerns with the service.

Records relating to people's risks and care needs were incomplete and contained misleading information. As a result, staff did not receive all the information and guidance they required to provide care that met people's needs. People’s care needs were not regularly reviewed.

Some aspects of environmental safety were not effectively managed. Insufficient fire safety measures were in place and some areas of the home were not clean or maintained in a way to mitigate infection risks.

We found there to be insufficient numbers of staff working at the service to keep people safe. People were at risk of experiencing unsafe care and treatment as a result. Staff were safely recruited.

People’s nutritional needs were not properly assessed, and people did not receive the support they needed with eating and drinking. This put people at risk of malnutrition.

Improvements were required to staff training. Staff had not received all the training they required, and reliable records were not kept of staff training.

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. However, the policies and systems in the service did not support this practice.

A complaints procedure was in place and written complaints had been investigated by the registered manager. However, problems raised verbally were not always recorded as complaints, and therefore weren’t dealt with in accordance with the provider’s policy.

People did not always receive timely support to meet their ongoing health needs and health monitoring. People were supported to access relevant health and social care professionals when they were unwell.

We found individual staff to be caring and compassionate towards people. However, due to staffing levels at the service they lacked opportunities to spend time with people. Care being delivered was often task focussed.

People received their medicines as prescribed and staff understood their roles and responsibilities to safeguard people from the risk of harm.

We have identified breaches in relation to the management of risks to people, meeting people’s eating and drinking needs, staffing levels, staff training and the governance of the service at this inspection.

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 requires improvement (29 December 2018) and the provider was in breach of one regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been made and the provider was still in breach of regulations.

Why we inspected

This was a planned inspection.


We have imposed conditions on the provider's registration, for more information please see the end of the report.

We will meet with the provider to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The overall rating for this servi

Inspection areas



Updated 24 March 2020

The service was not safe.

Details are in our safe findings below.


Requires improvement

Updated 24 March 2020

The service was not always effective.

Details are in our effective findings below.


Requires improvement

Updated 24 March 2020

The service was not always caring.

Details are in our caring findings below.


Requires improvement

Updated 24 March 2020

The service was not always responsive.

Details are in our responsive findings below.



Updated 24 March 2020

The service was not well-led.

Details are in our well-Led findings below.