Leyland Lodge

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 newly registered service. This key question has been rated Good.

This service scored 69 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff explained how they would respond to an incident or accident, and confirmed information was shared amongst the team.

Systems were in place to log accidents and incidents electronically through the providers’ digital recording system, including sections detailing actions taken and whether next of kin were informed.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

We observed interactions between staff members a number of times, these were appropriate and people were at ease approaching both staff and managers.

Some people had restrictions in place under a DoLS (Deprivation of Liberty Safeguards). Staff showed a good understanding of those restrictions and understood how to support them safely within these restrictions ensuring their human rights were protected.

Staff explained who they would report to if they had any concerns regarding colleagues or manager’s conduct.

The provider ensured staff had up to date training in safeguarding and the safeguarding policy guided staff around the types and signs of abuse. Staff were confidently able to tell us what signs of abuse they would look for and who they would report concerns to.

People confirmed they generally felt safe. One resident told us “I feel safe here”.

The provider did not always work well with people to understand and manage risks.

Risks were identified on peoples’ needs assessments but associated risk assessments were not always completed to mitigate those risks.

However, the provider was responsive to risk; we saw completed action plans following incidents and accidents

Staff had a good level of training and were generally knowledgeable about risks to people.

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 systems in place to monitor and report any maintenance issues and records were well presented and up to date, including where remedial action was required and once completed. We saw a chair which needed to be repaired, but it had already been recorded to maintenance. We also saw vacant rooms used for storage which were all on the top floor behind a locked communal door, ensuring people remained safe by having no access to it.

The provider had appropriate safety checks in place, and external servicing was carried out within the required timeframes.

Staff confirmed they had received training in fire safety and attended fire drills. Firefighting equipment was available throughout the building and was inspected within required timeframes.

The provider did not always make sure there were enough qualified, skilled and experienced staff. .

Staff were recruited safely, and the appropriate checks had been completed, the personnel files were clear and well presented. Staff received a thorough induction, and there was a good level of training and ongoing support. One staff member told us” [The management] are very supportive, they don’t mind you asking questions, you can ask as many times as you need to.”

However, staff members told us there were not always enough staff on duty. We were told, “They aim for 5 staff on during the day, but this doesn’t always happen. It puts pressure on us if someone is on a break, someone else is out on 1:1 support, we can’t always get out with people when they want to go out. "The registered manager confirmed that she steps in and acts as a support worker when there is a shortage of staff.

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.

Housekeepers were available daily and we observed the home to be clean and tidy. The housekeeper was cleaning floors during our visit and displayed the correct warning signs. Staff maintained a good level of cleanliness in the kitchen, and systems were in place to ensure compliance with food hygiene standards.

Staff supported people to maintain their personal hygiene where required, PPE was available throughout the building. Care records evidenced regular support with personal care.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

The registered manager ensured appropriate systems and processes were in place to order, store and dispose of medication safely, including controlled drugs. Records were completed without error. People’s medicines were regularly reviewed.

Staff with responsibility for administering medicines told us they had received appropriate training and oversight to carry out this task and had also been supported by management to induct other staff members in medication administration.

However, we found the MAR charts difficult to follow and staff could not always easily identify when a specific medicine had been administered. During our checks we found no errors in administration. Following feedback, the registered manager assured us that they would alter their systems to be more user friendly.