Leighton Forest

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. This is the first assessment for this service. This key question has been rated requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety.

The service was in breach of legal regulations in relation to safe care and treatment and safeguarding. Safeguarding concerns were not always identified and reported. Incidents were not always well documented or managed. Care plans did not always contain enough information about managing risks. Medicines were not always managed safely. IPC risks had not always been managed.
 

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Where people had experienced emotional distress, this had not always been appropriately documented. This meant leaders could not always investigate safety events and report safeguarding concerns. This increased the risk of lessons not being learnt to manage or prevent the risk of future occurrences. Some of these incidents had resulted in people experiencing potential physical aggression or unwanted physical contact.

In response to our concerns, the provider held a workshop/training session with staff on the importance of good record-keeping and documentation. The provider told us they would improve their systems for documenting when people experienced emotional distress to provide better insight into future care planning. We will check for sustained improvement at our next inspection.

However, where people had experienced accidents, such as falls, staff had reported these appropriately and sought medical advice where needed. Leaders had reviewed and investigated these accidents. A relative told us, “The thing I am most impressed with is their continuous desire to improve. Their attitude is just amazing; the staff are so caring. Yes, there are hiccups and bumps on the way, of course.”

Systems were in place to assess people’s needs before they started using the service. This allowed the provider to set up people’s initial care plans to include information about their care needs, routines, and preferences. The service worked well with external health professionals to escalate ill or deteriorating health. People had access to advocates to support them to have their views understood. When reflecting on visiting the service before the person moved in, a relative told us, “The first person to show me around was [Nominated Individual] around 17:30. They were really positive and good to show us around even though it was late.”

People had not always been protected from abuse and improper treatment. This was due to staff incorrectly documenting incidents such as altercations or unwanted physical contact between people, which resulted in these not going to the registered manager for review. This prevented them from independently identifying these concerns.

In response to our concerns, the provider completed notifications to the local authority safeguarding team and CQC retrospectively. They took immediate action, such as retraining staff, reviewing staffing levels, and reviewing how they supported people by utilising all available space in their environments. The provider carried out an internal investigation and shared with us their learning and plan for immediate improvement.

However, people and their relatives told us they felt people were safe. A person said, “I feel safe because of good carers around.”
 

The service did not always plan to meet people’s care safely. People’s care plans and risk assessments did not always provide enough information on how staff should support people with known risks. These risks included, safely supporting people known to regularly experience emotional distress, the safe use of bedrails and changes to people’s mobility.

In response to our concerns, the provider made referrals to external health professionals to review risks relating to people’s safety with using bedrails. The provider also reviewed their policy and systems around this. The provider told us they would include relevant information about incidents or adverse events in care plans to better inform care planning.

However, where people needed equipment such as sensors and safety mats, these were in place. The staff we spoke with were knowledgeable about risks people could experience and how to manage this. For example, a staff member told us it was important to ensure a person’s belongings were not moved to prevent them from experiencing distress.
 

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The provider had invested significantly in improving the environment since taking over the service from the previous provider. The provider had an established system to report and act upon any environmental concerns and improvements needed. Equipment such as hoists, fire safety equipment, and people’s alternating air flow mattresses were managed safely and serviced in line with requirements.

There were enough staff to support people safely. Staff told us they felt there were enough staff. People and their relatives felt that overall, there were enough staff, and they responded quickly. The provider had safe recruitment systems, which included undertaking risk assessments when candidates had gaps in employment. Staff told us they received regular supervisions and team meetings. A person told us, “Carers are friendly, and somehow, they always know where I am. They come and find me for meals.” A staff member told us that in relation to the training and induction they received, “I was given a full set of e-learning to do, as well as face-to-face training such as Basic Life Support, Fire Safety, and Moving and Handling. Even though I have had training before, they put me through it all again, which I thought was good.”

Improvements were needed in some IPC practices. We observed 2 people had shower products in their bedrooms that belonged to other people. This increased the risk of cross-infection. We observed some food items in a communal kitchenette had not been labelled on opening, these items had a ‘use by’ date based on the opening date. In response to these concerns, the registered manager retrained staff on their expectations around environmental cleanliness, and the food items of concern were removed.

We observed that a person’s catheter bag was overdue changing for 3 days, which could increase the risk of urinary tract infections. The registered manager acted on this immediately and introduced systems to alert staff to check and change these when due.

However, communal spaces and people’s bedrooms were clean and malodour-free. A person told us, “I like the place because it's clean, the carers are kind, and I have the freedom to go and do whatever I like.”

The provider did not always make sure that medicines and treatments were safe. We identified concerns with people’s prescribed topical creams. These medicines had not been dated upon opening or discarded in line with the manufacturers’ instructions. Staff had inconsistently documented that they had given or applied topical medicines to people. Staff did not always record the site where they applied prescribed transdermal medicines. Prescribed thickener used to modify the consistency of fluids was left unsecured on the first day of our assessment. Not always ensuring people received their prescribed medicines safely and correctly increased health-related risks to them.

In response to our findings, the provider formally supervised staff, retrained them and arranged for medicines of concern to be removed or replaced. They showed us evidence that they planned to introduce an electronic medicine recording system to manage these risks better. We will check for sustained improvement at our next inspection.

However, we observed that other medicines, such as those in tablet form and controlled drugs, were stored safely. When administering medicines to people, staff sought consent and did so respectfully. Where people required medicines to be taken on an ‘as required’ basis, there were person-centred care plans around this.