Archived: Leaf Park Dementia Village

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.

Leaf Park Dementia Village is a residential care home providing accommodation and personal care for up to 19 people. At the time of our inspection there were 19 people using the service all of whom were living with varying levels of dementia. The service consists of two units, one on the ground floor (Urban) and one on the first floor (Homely), each of which has separate adapted facilities. There was also accessible outside space, and communal areas where people could spend time together.

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

Risks to people were not always assessed and managed in a way which ensured people's safety. Actions had not always been taken to minimise risks. This put people at risk of injury or their health deteriorating.

There were risks in the environment which had not been addressed by the provider. This included items that people could accidently ingest. Infection control procedures needed to be more robust to ensure the service was clean and hygienic. Medicines were not always being managed safely at the home.

There were not enough staff deployed at the service which put people at risk. The service had not effectively assessed the dependency needs of people so they could calculate accurate staffing levels. Staff had not received some training relevant to their role to ensure good practice within the service.

People we spoke with were accepting of the service provided to them. People told us the staff were kind when interacting with them, but sometimes the staff member supporting them would be called away because other people’s needs were more urgent. People's privacy and dignity was not always considered.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice. The principles of the Mental Capacity Act were not properly understood by the staff or management team.

People's nutritional and hydration needs were not appropriately managed and this placed them at risk of harm. The quality of food provided was poor at times and choices were limited or not promoted to people. The serving of meals to people did not ensure they were hot and appetising and hygiene standards needed improvement.

People were not always referred in a timely manner to specialist professionals such as dieticians. Relatives gave us examples of when they had to prompt the service to seek professional advice.

Evidence based guidance was not being utilised to enhance people’s experiences when living with dementia. The provider had not designed and decorated the premises in a way that supports people living with dementia.

Each person had a care plan in place but there was not always sufficient detail to guide staff. Some areas of people's care hadn't been planned to reduce risk. We were not assured that the provision of activity was meeting people’s individual and specialist needs.

There was a complaints procedure in place. Relatives felt able to raise issues, but they were not always confident changes would be made as a result.

The provider's auditing systems for monitoring and improving the quality of the service had not been effective, because people were not always receiving safe care as risks had not always been mitigated. This placed people at continued risk of harm.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

This service was registered with us on 22 October 2020 and this is the first inspection.

Why we inspected

The inspection was prompted in part due to concerns received about the quality of people’s care, including people’s safety, their dietary intake, and environmental concerns. A decision was made for us to inspect and examine those risks.

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, effective, caring, responsive and well-led sections of this full report.

Following the inspection, the provider took steps to mitigate risks, such as ensuring the environment was safe by locking away chemicals and creams, arranging training sessions for staff, and had begun updating care plans to ensure people’s needs were clearly documented. They had also referred people to external professionals for their advice.

The overall rating for the service is Inadequate based on the findings of this inspection.

Enforcement and Recommendations

We have identified breaches in relation to safe care and treatment, medicines, consent procedures, staffing, nutrition, person-centred care, and governance at this inspection.

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 work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect. We will also request an action plan from the provider to understand what they will do to improve the standards of quality and safety.

The overall rating for this service is ‘Inadequate’ and the service is therefore 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.