Leighton Rose Care Home

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 meant people were safe and protected from avoidable harm.

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 promoted a positive culture of learning and improvement. Staff understood reporting processes and described learning being shared through meetings, handovers and discussions. Leaders demonstrated a commitment to reflecting on concerns and embedding improvements.

The provider worked effectively with healthcare professionals including GPs, physiotherapists and specialist nurses. Systems were in place to share information, monitor changing needs and ensure continuity of care.

The provider did not always ensure safeguarding concerns were recognised, escalated and reported appropriately. During our assessment we identified concerns which had not been referred to the local authority or CQC. We found staff had not recorded these concerns correctly in records to ensure the provider could review. This reduced assurance safeguarding systems were openly shared, consistently effective in identifying and responding to potential abuse or harm.However, leaders responded positively when these concerns were brought to their attention. The provider immediately contacted the local authority, sought advice and submitted safeguarding notifications to the CQC. Staff told us concerns could be escalated to senior leaders and, where necessary, outside the organisation.
 

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Risk assessments reflected individual needs and promoted a balance between safety and independence. Risks were reviewed regularly and staff had access to guidance about how to support people safely. A relative told us, “When [Person] had fallen, strategies were put in place to prevent further falls immediately.” A person said, "Yes, I feel safe living here because I’m cared for."

The provider maintained a safe and well-maintained environment. The service was clean and equipment was subject to routine servicing, maintenance and safety checks. For example, records evidenced regular monitoring of fire safety systems, hoists, lifts, emergency lighting, bedrails and water systems.

The provider generally ensured there were enough staff available to meet people's immediate safety needs. We observed staff responding to people in a calm and caring manner and people did not experience unsafe delays in care.However, feedback from people, relatives and staff indicated staffing levels were not always sufficient to consistently meet people's wider wellbeing and engagement needs. Staff told us busy periods, staff absence and high dependency needs could place pressure on the team and reduce opportunities for meaningful interactions with people. When asked if there were enough staff, a relative said, “No, absolutely not. I don’t understand how it works. On the [Dementia Community] there are not enough staff.” People also told us they sometimes had to wait for support, one person said, “Sometimes I have waited so long in the morning in the end I come down in my nightdress.” And, "I often say I don’t think there’s enough staff." In response to this feedback, the provider told us they will strengthen monitoring of call bell usage by reviewing both response times and repeat calls and will be introducing ongoing checks to ensure peoples’ needs are fully met and any concerns are identified and addressed promptly.

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. The service was clean and staff followed appropriate infection prevention and control practices. People and staff spoke positively about standards of cleanliness.

Medicines were managed safely and people received medicines as prescribed. Staff administering medicines had received appropriate training and competency assessments. Medicines oversight systems were in place and records demonstrated medicines were stored and administered safely. Whilst some PRN protocols would benefit from additional detail, medicines management was safe overall.