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The Leys Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 10 February 2021

About the service

The Leys is a residential care home that can provide care and support for older people and people living with dementia. The service is registered to provide personal care to a maximum of 33 people. At the time of inspection 14 people were using the service.

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

We found continued issues with management oversight. Audits had not identified the concerns raised during the inspection.

Information documented on people’s needs required improvement. We found missing information within care plans, and not all risk assessments had been completed. Care plans required reviewing and information logged consistently. Some risk assessments needed implementing.

Documentation of care tasks was inconsistent. We found gaps in the recording of safety checks, repositioning checks and the recording of peoples nutritional and hydration needs.

Medicine management required improvement. We found not all information had been documented. People received their medicines by trained staff.

People were supported by staff who had been safely recruited, appropriately trained and who knew them well.

People were protected from abuse by the systems and processes implemented. Staff understood how to recognise abuse and how to report it.

Complaints, suggestions and feedback had been appropriately managed and actions implemented to improve the service.

People were protected from infections. Staff wore appropriate personal protective equipment (PPE) and cleaning schedules were in place to ensure the service was clean and hygienic.

For more details, please see the full report which is on the CQC website at

Rating at last inspection and update

The last rating for this service was inadequate (published 24 March 2020) and there were multiple breaches of regulation.

The provider completed an action plan and had conditions put on their registration following the last inspection.

At this inspection enough improvement had not been made and the provider was still in breach of regulations 12 and 17. Other areas had improved and the provider was no longer in breach of regulations 13 and 18.

This service has been in Special Measures since 19 March 2020.

Why we inspected

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from Inadequate to requires improvement. This is based on the findings at this inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively.

We have found evidence that the provider needs to make improvements.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for The Leys on our website at


We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service to keep people safe and to hold providers to account where it is necessary fo

Inspection areas


Requires improvement

Updated 10 February 2021

The service was not always safe.

Details are in our safe findings below.


Requires improvement

Updated 10 February 2021


Requires improvement

Updated 10 February 2021


Requires improvement

Updated 10 February 2021



Updated 10 February 2021

The service was not well-led.

Details are in our well-led findings below.