Background to this inspection
Updated
1 March 2023
The inspection
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.
As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.
Inspection team
The inspection site visit was completed by two inspectors and a specialist medicines inspector. An Expert by Experience made telephone calls to relatives to seek their feedback on the service. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.
Service and service type
Leaf Park Dementia Village is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Leaf Park Dementia Village is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
Registered Manager
This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.
At the time of our inspection there was a registered manager in post.
Notice of inspection
This inspection was unannounced.
Inspection activity started on 31 August 2022 and ended on 14 September 2022 when detailed feedback was given. We visited the location’s service on 31 August 2022.
What we did before inspection
We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all this information to plan our inspection.
During the inspection
The people who used the service were unable to tell us about their experience of receiving the service, so observations of care and support were made. We spoke with six relatives, received written feedback from a seventh relative and spoke with ten staff members. These included the nominated individual for the provider (the nominated individual is responsible for supervising the management of the service on behalf of the provider), a compliance manager, two business support managers and six care staff. We received written feedback from a further three care staff members. Two health professionals also provided us with feedback; one verbally and one in writing.
A selection of records was also viewed, and these included the care plans and associated records for nine people who used the service. The medicines records for ten people were also assessed. The governance records viewed included policies and procedures, staff recruitment records, training information, quality monitoring audits and maintenance records.
Updated
1 March 2023
About the service
Leaf Park Dementia Village is a residential care home providing personal care and accommodation to up to 19 people. The service provides support to older people living with dementia. At the time of our inspection there were 15 people using the service.
The home provides specialist dementia care across two floors accessed by a lift. All rooms are ensuite and there are communal living areas as well as an enclosed garden.
People’s experience of using this service and what we found
People were not protected from the risk of abuse as the systems in place had failed to identify allegations of abuse and protect those involved. Not all staff had the knowledge of how to report safeguarding concerns outside of their organisation. The registered manager had failed to share safeguarding concerns with other stakeholders as required and in order to ensure people’s safety.
The culture within the home was not consistently open and staff did not feel able to contribute to the running of the home or in the improvements required. They told us they did not feel engaged or listened to. Incidents were not always discussed with them in order to reflect and learn lessons in order to better improve the quality and safety of the service.
We could not be assured that people consistently received their medicines as prescribed and best practice was not always followed.
Whilst improvements had been made since our last inspection, the governance systems in place had not been fully effective at identifying and rectifying concerns. For example, the relatives we spoke with told us there were still improvements needed in communication. Not all safety incidents had been reported to CQC as required by law and we found records were not consistently accurate, complete or contemporaneous.
We could not be fully assured that there were enough staff deployed to meet people’s needs in an individualised way. Relatives had mixed opinions on staffing levels and evidence showed the number of staff the provider had assessed as being required, had not always been on shift.
We could not be fully assured that people were supported to have maximum choice and control of their lives and that staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. However, records did not fully demonstrate this approach and improvements are required.
Improvements had been made in relation to risk management and the systems in place had been effective at keeping people safe from physical harm. We saw mitigating measures were in place to address risk factors and that these were being followed.
Improvements had also been made in infection prevention and control processes. We found the premises to be clean although some improvement is further needed to ensure equipment remains consistently hygienic and clean. Government guidance had been followed in relation to COVID-19 management and visiting. Some redecoration has been completed to make the environment more suited to those people living with dementia.
The service was now working well with healthcare professionals and we saw prompt referrals had been made as required. Healthcare professional recommendations had been followed and this had benefited the people who lived at Leaf Park Dementia Village. Staff had received training and supervisions as well as had their competency checked. People’s nutritional needs had been met.
The provider had an action plan in place to continue to address the shortfalls and acknowledged further improvements were required. Whilst they acknowledged further development of the service was needed, staff and relatives told us the provider had been working hard to implement change. Out of the seven relatives that provided us with feedback, five told us they would recommend the home with one telling us, “I would recommend the home as they seem to want to do the right thing.”
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was inadequate (report published on 15 June 2022) and there were breaches of regulations. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider remained in breach of regulations.
Why we inspected
We received concerns in relation to medicines management, adherence to the Mental Capacity Act 2005 (MCA), cleanliness, risk management and governance. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service remains inadequate based on the findings of 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 COVID-19 and other infection outbreaks effectively.
We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report.
You can see what action we have asked the provider to take at the end of this full report. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Leaf Park Dementia Village on our website at www.cqc.org.uk.
Enforcement and Recommendations
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.
Follow up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.
The overall rating for this service is ‘Inadequate’ and the service remains in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.
If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.
For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.